Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Honor the resident’s right to manage his or her financial affairs.

Based on record review and interview, the facility failed to ensure each resident was
afforded the right to manage his/her financial affairs, when the facility failed to advise
residents of money held in the facility operating account that belonged to the resident.
The facility failed to deposit funds, in excess of $100 for residents receiving Medicare
and $50 for residents receiving Medicaid, in an interest bearing account that was separate
from any of the facility’s operating accounts, and credit all interest earned on
resident’s funds to that account. The deficient practice affected 71 residents (Residents
#13, #38, #57, #68, #71, #80, #83, #113, #128, #154, #156, #168, #169, #170, #171, #172,
#173, #174, #175, #176, #177, #178, #179, #180, #181, #182, #183, #184, #185, #186, #187,
#188, #189, #190, #191, #192, #193, #194, #195, #196, #197, #198, #199, #200, #201, #202,
#203, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217,
#218, #219, #220, #221, #222, #223, #224, #225, #226 and #227). Also, the facility failed
to provide the Social Security personal spending allowance on a monthly basis to the
residents for two residents (Residents #45 and #167). Additionally, the facility failed to
use the personal funds of a resident exclusively for the resident and only when authorized
in writing for 16 residents (Residents #13, #17, #21, #31, #35, #69, #77, #84, #93, #107,
#122, #132, #133, #148, #154 and #167) out of a sample of 28 residents’ funds reviewed.
The facility census was 177.
1. Record review of the facility maintained Accounts Receivable A/R Aging Report for the
period 5/1/18 through 5/13/19, showed the following residents with personal funds held in
the facility operating account:
Resident Amount Held in Operating Account
#13 $ 435.50
#38 $ 48.00
#57 $ 158.93
#68 $ 773.00
#71 $4,414.47
#80 $ 875.00
#83 $ 531.08
#113 $3,438.00
#128 $ 700.00
#154 $ 946.00
#156 $ 461.70
#168 $1,055.57
#169 $ 170.50
#170 $ 112.87
#171 $ 20.00
#172 $1,750.00
#173 $ 1.18
#174 $ 427.22
#175 $1,416.00
#176 $ 295.49
#177 $ 585.38
#178 $1,595.83
#179 $ 588.88
#180 $ 854.00
#181 $ 165.00

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 1)
#182 $1,253.23
#183 $ 157.00
#184 $1,574.15
#185 $ .03
#186 $2,356.00
#187 $ 543.70
#188 $1,925.00
#189 $ .08
#190 $ 106.93
#191 $ 705.37
#192 $ 786.05
#193 $ 75.00
#194 $ 4.00
#195 $1,183.67
#196 $1,354.10
#197 $1,910.60
#198 $ 359.16
#199 $1,969.12
#200 $ 594.80
#201 $ 30.00
#202 $ 15.85
#203 $ 244.00
#204 $ 1.48
#205 $1,173.00
#206 $ 240.00
#207 $ 140.76
#208 $ .23
#209 $ 285.36
#210 $1,500.00
#211 $ 207.77
#212 $ .98
#213 $ 751.70
#214 $1,584.00
#215 $1,002.00
#216 $ 720.00
#217 $1,190.45
#218 $ .27
#219 $3,775.00
#220 $ 509.47
#221 $ 947.79
#222 $1,129.00
#223 $ 60.00
#224 $1,731.00
#225 $1,278.89
#226 $2,130.00
#227 $2,025.00
Total $61,351.59
During an interview on 5/13/19 at 2:15 P.M., the administrator said the facility is aware
of the credits in the operating account and that the facility fell behind issuing the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 2)
refunds in the operating account. The refunds are valid refunds and should be refunded.
2. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed Resident #45 did not receive his/her $50.00 spending allowance
monthly, but received several monthly allowances at one time.
Month Date Received
12/2018 03/01/19
01/2019 03/01/19
02/2019 03/01/19
During an interview on 5/13/19 at 1:30 P.M., the business office manager said he/she was
not sure why the previous office staff did not deposit Resident #45’s Social Security
allowance monthly.
3. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed Resident #167 did not receive his/her full $50.00 spending
allowance monthly for the following months:
Month
1/2019
2/2019
3/2019
4/2019
5/2019
During an interview on 5/13/19 at 1:30 P.M., the business office manager said he/she was
not sure why the full Social Security allowance was not given to Resident #167.
4. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #13’s account:
Date Amount Description
8/8/18 $50.00 Personal Needs Items
9/13/18 $50.00 Resident Advance Cash
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #13’s withdrawals.
5. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #17’s account:
Date Amount Description
12/3/18 $25.00 Resident Advance Cash
2/19/19 $10.00 Resident Advance Cash
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #17’s withdrawals.
6. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawal from Resident #21’s account:
Date Amount Description
1/31/19 $81.27 Personal Needs Items
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #21’s withdrawal.
7. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawal from Resident #31’s account:
Date Amount Description
4/22/19 $30.00 Resident Advance Cash
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #31’s withdrawal.
8. Record review of the facility maintained Resident Statement for the period 5/1/18
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 3)
through 5/13/19, showed the following withdrawals from Resident #35’s account:
Date Amount Description
7/23/18 $30.68 Personal Needs Items
1/7/19 $30.68 Personal Needs Items
During an interview on 5/13/19, at 1:00 P.M., the business office manager said the $30.68
withdrawals were for cigarettes. There was no written authorization from any resident when
the purchase was for cigarettes.
9. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #69’s account:
Date Amount Description
2/20/19 $33.90 Personal Needs Items
3/20/19 $44.59 Personal Needs Items
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #69’s withdrawals.
10. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #77’s account:
Date Amount Description
11/15/18 $ 99.20 CC Pymt
11/27/18 $ 9.25 Insurance Premiums
12/04/18 $123.79 Telephone Charges
12/11/18 $100.80 Credit Card Payment
1/11/19 $ 50.00 Resident Advance Cash
1/24/19 $ 5.00 Telephone Charges
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #77’s withdrawals. The business office
manager also said he/she did not know why there would be an additional $9.25 for insurance
premiums withdrawn.
11. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #84’s account:
Date Amount Description
6/5/18 $358.88 Personal Needs Items
7/9/18 $298.47 Personal Needs Items
7/11/18 $718.06 Personal Needs Items
9/17/18 $820.65 Misc. Rec. Storage
10/23/18 $259.96 Care Cost Payment
10/23/18 $259.96 Care Cost Payment
1/22/19 $4,241.11 Care Cost Payment
2/19/19 $330.53 Personal Needs Items
4/5/19 $193.88 Personal Needs Items
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #84’s withdrawals. The business office
manager also said he/she was not sure why the additional amount was withdrawn for 10/2018
since the care cost payment of $3,397.40 was already withdrawn for 10/2018. The business
office manager also was not sure why the amount withdrawn for 1/2019 was more than
$3,728.36.
12. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawal from Resident #93’s account:
Date Amount Description
07/09/18 $131.25 Professional Fee
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 4)
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #93’s withdrawal and did not know what the
fee was for.
13. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #107’s account:
Date Amount Description
6/15/18 $100.00 Personal Needs Items
7/2/18 $100.00 Personal Needs Items
4/4/19 $ 20.00 Resident Advance Cash
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #107’s withdrawals.
14. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #132’s account:
Date Amount Description
7/11/18 $35.00 Personal Needs Items
10/30/18 $10.00 Resident Advance Cash
2/14/19 $24.00 Resident Advance Cash
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #132’s withdrawals.
15. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #133’s account:
Date Amount Description
1/17/19 $257.21 Insurance Premiums
1/18/19 $ 12.40 Insurance Premiums
3/8/19 $302.30 Insurance Premiums
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #133’s withdrawals. The business office
manager also was not sure why the Insurance Premiums were not the usual premium of $297.
16. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #148’s account:
Date Amount Description
11/5/18 $50.00 Resident Advance Cash
4/4/19 $50.00 Resident Advance Cash
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #148’s withdrawals.
17. Record review of the facility maintained Resident Statement for the period 5/1/18
through 5/13/19, showed the following withdrawals from Resident #154’s account:
Date Amount Description
9/10/18 $200.00 Resident Advance Cash
12/21/18 $ 82.75 Doctor Bill
3/5/19 $ 60.00 Tobacco
3/15/19 $ 10.00 Resident Advance Cash
3/15/19 $ 10.00 Resident Advance Cash
4/10/19 $ 10.00 Resident Advance Cash
4/10/19 $ 60.00 Resident Advance Cash
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization was not obtained for any tobacco/cigarette purchases and there was no
written authorization located for Resident #154’s other withdrawals.
18. Record review of the facility maintained Resident Statement for the period 5/1/18
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 5)
through 5/13/19, showed the following withdrawals from Resident #167’s account:
Date Amount Description
10/11/18 $71.17 Telephone Charges
4/5/19 $45.30 Telephone Charges
During an interview on 5/13/19, at 3:50 P.M., the business office manager said written
authorization could not be located for Resident #167’s withdrawals.
U4413

F 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify each resident of certain balances and convey resident funds upon discharge,
eviction, or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
U4413
Based on interview and record review, the facility failed to provide Medicaid spend down
letters when the balance of the resident’s trust fund account exceeded $2,800.00. This
deficient practice affected four residents (Residents #77, #84, #107 and #122).
Additionally, the facility failed to provide a final accounting of individual resident
trust fund balances within 30 days to the individual or probate jurisdiction administering
the resident’s estate for two residents (Residents #156 and #157). The facility census was
177.
1. Record review of the facility’s maintained Resident Trust Fund Account for the period
[DATE] through [DATE], showed the facility unable to provide documentation showing SSI
resource limit letters were provided to residents, their designee, guardian and/or
conservator when the resident trust fund account reached a balance of $2,800.00 or $200.00
from the SSI resources limit of $3,000.00.
Record review on [DATE] of the Resident Trust Fund Accounts of Residents #77, #84, #107
and #122, showed Resident Trust Fund Account balances that exceeded $2,800.00 several
times throughout the period of [DATE] through [DATE].
During an interview on [DATE] at 1:30 P.M., the business office manager said the previous
business office manager did not provide spend down letters to residents, their designee or
guardians when the balance of the resident trust fund account reached $2,800.00, or
$200.00 from the SSI resources limit of $3,000.00.
2. Record review of the facility maintained Expired Report for the period [DATE] through
[DATE], dated [DATE], showed Resident #156 expired on [DATE].
Record review of the facility maintained Resident Trust Fund Ledger for the period [DATE]
through [DATE], showed Resident #156 had $2,104.77 held in the resident trust fund account
as of [DATE] (152 days after Resident #156 expired).
During an interview on [DATE] at 1:00 P.M., the business office manager said Resident #156
received Medicaid and the previous business office manager did not submit a Personal Funds
Balance Report to Social Services showing the balance remaining in Resident #156’s
resident trust account within 30 days of expired date.
3. Record review of the facility maintained Expired Report for the period [DATE] through
[DATE], dated [DATE], showed Resident #157 expired on [DATE].
Record review of the facility maintained Resident Trust Fund Ledger for the period [DATE]
through [DATE], showed Resident #157 had $145.39 held in the resident trust fund account
as of [DATE] (80 days after Resident #157 expired).
During an interview on [DATE] at 1:00 P.M., the business office manager said Resident #157

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
received Medicaid and the previous business office manager did not submit a Personal Funds
Balance Report to Social Services showing the balance remaining in Resident #157’s
resident trust account within 30 days of expired date.

F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on observation and interview, the facility failed to ensure residents who live on
the 100, 200 and 400 halls could exercise their right to private communication when they
failed to replace the resident telephones in a timely manner. The facility census was 177.

1. During an interview on 5/16/19 7:22 A.M., Resident #42 said he/she could not make a
private phone call. There used to be cordless phones at the nurse’s stations, but since
the facility rewired the phone system about three months ago, they took the cordless
phones away and never replaced them. If he/she wanted to make a call, he/ she had to ask
the nurse to dial and then could only go as far away as the cord would stretch. There were
always staff and other residents around. He/she felt bad about tying up the phone because
the nurse needed to use it too.
2. During an interview on 5/16/19 at 7:26 A.M., Nurse U, who worked regularly on the 100
Hall, said residents could use the desk phone or the cordless phone . Residents could take
the cordless phone to their room to use. Nurse U was unable to locate the cordless phone.
He/she said it sometimes happened when residents left the phone in their room and
eventually it showed back up. The locator button was pressed, but Nurse L was unable to
locate the phone.
3. During an interview on 05/16/19 08:11 A.M., Nurse L, who worked regularly on the 200
Hall, said the only phone available for resident use was at the nurse’s station. They used
to have a cordless phone, but there were wiring issues and it was taken away. They
encouraged residents to have cell phones.
4. Observation on 5/16/19 at 1:24 P.M., showed staff informed Resident #86 he/she had a
phone call at the 100 Hall nurse’s station. The resident wheeled up to the nurses’s
station and took the phone from staff. The resident could be overheard having a private
conversation while three residents, four staff, two visitors and a hospice representative
sat or stood around or near the nurse’s station within hearing distance of the
conversation. At 1:33 P.M., the resident ended his/her conversation, gave the phone back
to staff and wheeled away.
During an interview on 5/17/19 at 7:23 A.M., Resident #86 said residents always had to use
the phone at the nurse’s station. He/she would prefer to have a place to make calls
privately. He/he did not like having to take calls where everyone could listen in.
5. During an interview on 5/17/19 at 7:17 A.M., three nursing staff on the 400 Hall
confirmed the only phone currently available for resident use was the one at the nurse’s
station.
6. Review of the Resident’s Rights information provided to all residents in the admission
packet, showed residents had the right to privacy to make phone calls.
7. During an interview on 5/17/19 at 10:10 A.M., the administrator agreed the facility was
responsible to ensure residents could make private phone calls. He was not aware the
cordless phones on the 100, 200 and 400 Halls were not in working order or available for

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
resident use.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement person-centered comprehensive care plans to meet preferences and goals and
address residents’ medical, physical, mental and psychosocial needs, by not including
depression, pressure ulcers, oxygen use, activities, restorative therapy, pain,
contractures, paralysis and [MEDICAL CONDITION] on the care plans, for eight of 35 sampled
residents (Residents #23, #151, #88, #49, #25, #28, #44 and #77). The census was 177.
1. Review of Resident #23’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/17/19, showed the following:
-No cognitive impairment;
-Total dependence on staff for activities of daily living;
-Upper and lower extremity impairment;
-Incontinent;
-No antidepressant medication administered in past 7 days;
-[DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
-An order, dated 3/4/19, for [MEDICATION NAME] (antidepressant medication) 10 milligrams
(mg), give one tablet by mouth in the morning related to major [MEDICAL CONDITION];
-An order, dated 3/4/19, for duloxetine (antidepressant medication) 20 mg, give one
capsule by mouth in the morning related to major [MEDICAL CONDITION].
Review of the resident’s care plan, updated 2/17/19, showed no mention of the resident’s
[MEDICAL CONDITION] diagnosis, goals, or interventions associated with care.
2. Review of Resident #151’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Required extensive assistance from staff for transfers and dressing and required limited
assistance for hygiene and toileting;
-[DIAGNOSES REDACTED].
-At risk for pressure ulcers (Pressure injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure or friction).
Review of the resident’s (MONTH) 2019 POS, showed the following orders:
-An order, dated 4/30/19, to cleanse the right great toe with wound cleanser (WC) or
normal saline (NS) and apply [MEDICATION NAME] (an antiseptic used for skin disinfection)
one time a day for prevention;
-An order, dated 4/30/19, to cleanse the left hip with WC or NS, apply calcium alginate
(CA, provides a moist environment for wound healing) and cover with dry dressing.
Review of the resident’s undated care plan, in use during the survey, showed staff failed
to address the resident’s skin issues, including prevention and treatment.
3. Review of Resident #88’s admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive staff assistance for transfers, mobility, hygiene, dressing and
toileting;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 8)
-[DIAGNOSES REDACTED].
-Should pain assessment interview be conducted? Yes. Interview: No presence of pain;
-Received oxygen therapy (treatment which provides extra oxygen the body needs to
function)? No.
During an interview on 5/13/19 at 11:11 A.M., the resident said he/she had constant pain
in his/her right knee from arthritis. He/she would like to go home, but could not complete
therapy to get stronger due to the constant pain. The resident wore a nasal canula (a
device used to deliver supplemental oxygen or increased airflow to a patient or person in
need of respiratory help) attached to an oxygen concentrator set at a flow rate of two
liters. He/she always wears oxygen.
During an interview on 5/16/19 at 1:05 P.M., the resident asked what could be done about
his/her knee pain. His/her pain was consistently at an 8 on a scale of 1-10. The resident
wore a nasal canula. The concentrator was set at a flow rate of two liters. The resident
said he/she did not have difficulty breathing when wearing the nasal cannula.
Review of the resident’s undated care plan, in use during the survey, showed, staff did
not address the resident’s frequent pain or non-pharmacological interventions if
appropriate. Staff also failed to address the resident’s need for and use of oxygen
therapy.
4. Review of Resident #49’s annual MDS, dated [DATE], showed the following:
-Cognition not assessed;
-Required total assistance from staff for all activities of daily living;
-Activity preferences not assessed;
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly activity assessment, dated 3/1/19, showed the
following:
-Resident receives 1:1’s two to three times a week;
-Resident enjoys when activity staff reads to him/her, play music, talk to him/her and
provide hand and nail care.
Review of the resident’s (MONTH) 2019 POS, showed an order, dated 4/29/19, to be seen by
restorative therapy (passive/active exercises to prevent further decline) for passive
range of motion to bilateral upper extremities and splints.
Review of the resident’s undated care plan, in use during the survey, showed staff did not
address the resident’s activity preferences or involvement in restorative therapy.
5. Review of Resident #25’s admission MDS, dated [DATE], showed the following:
-admitted : 5/2/19;
-Cognitively intact;
-Required extensive assistance from staff for hygiene, transfers, toileting and dressing;
-[DIAGNOSES REDACTED].
-Pain frequency: Frequently;
-Number of days resident has received opioids (medication used for pain relief) over the
last 7 days: 7.
Review of the resident’s electronic medical record (EMR), showed the following:
-An order dated 5/3/19, for [MEDICATION NAME] (used to treat moderate to moderately severe
pain) 5-325 mg, give one tablet by mouth every 6 hours as needed (PRN);
-An order, dated 5/3/19, for [MEDICATION NAME] Patch 5 % (used to relieve pain and numb
the skin), apply to skin topically in the morning for pain until 06/04/2019;
-An order, dated 5/3/19, for [MEDICATION NAME] 650 mg, give 650 mg by mouth every four
hours PRN for pain/temperature. Not to Exceed 4000 mg in a 24 hour period;
-An order, dated 5/7/19, for Biofreeze Gel 4 % (menthol topical [MEDICATION NAME])), apply
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 9)
to affected area topically every 6 hours PRN for pain;
-An order, dated 5/7/19, for Tylenol ([MEDICATION NAME], used to treat pain) 500 mg
tablet, give one tablet by mouth four times a day for pain;
-An order, dated 5/7/19, for [MEDICATION NAME] (medication used to treat nerve pain) 100
mg capsule, give one capsule by mouth three times a day for nerve pain.
During an interview 5/13/19 at 1:13 P.M., the resident said he/she had a fractured back
[MEDICAL CONDITION]. He/she wore a back brace to help with posture and healing. He/she had
frequent pain. The only thing that seemed to help is pain medication. Even with the
medication, his/her pain was at a 5 on a scale of 1-10.
During an interview on 5/16/19 at 1:23 P.M., Registered Nurse (RN) L said the resident had
continuous pain related to a fractured back. The resident had pain medications and usually
asked for PRN pain medications about twice during Nurse L’s 12 hour shift. The resident
also went to a pain clinic, which the family managed. The resident'[MEDICAL CONDITION] had
spread to the liver.
Review of the resident’s undated care plan, in use during the survey, showed staff did not
address the resident’s frequent pain, non-pharmacological interventions if appropriate and
signs or symptoms related to extensive use of pain medications. Staff also failed to
address the resident’s use of a back brace to promote comfort and healing of his/her
fractured back.
6. Review of Resident #28’s admission MDS, dated [DATE], showed the following:
-Original admission date of [DATE] and reentered on 1/23/19;
-Cognition not evaluated;
-Dependent on staff for all mobility and personal care;
-Impairment to all extremities;
-[DIAGNOSES REDACTED].
Observations of the resident on 5/13 at 1:48 P.M., 5/14 at 10:04 A.M. and 1:09 P.M., 5/15
at 6:30 A.M. and 1:17 P.M., 5/16 at 6:23 A.M. and 12:50 P,M, and 5/17/19 at 7:12 A.M.,
showed he/she lay in bed with arms, hands and legs contracted. He/she held a rolled cloth
in his/her right hand.
Review of the care plan, dated 2/28/19, showed the following:
-Problem: Alteration in mobility; Resident requires total assistance with all personal
care and mobility;
-Goal: Resident will transfer safely with staff assistance;
-Interventions: Total assistance of one to two staff with performing bed mobility, assure
resident has safe positioning in bed and total assistance of two staff and mechanical lift
with transfers;
-The care plan did not address the resident’s paralysis or contractures.

7. Review of Resident #44’s annual MDS, dated [DATE], showed the following:
-Original admission date of [DATE] and reentered on 9/25/18
-Severe cognitive impairment;
-Extensive assistance with all personal care;
-Unable to ambulate;
-Propels self in wheelchair;
-[DIAGNOSES REDACTED].
Observations on 5/13 at 2:54 P.M., 5/14 at 12:28 P.M., 5/15 at 10:01 A.M. and 1:22 P.M.
and 5/16/19 at 9:01 A.M. and 12:00 P.M., showed the resident sat in his/her wheelchair, a
trough (hard plastic device connected to the arm of the wheelchair to lay his/her arm on)
to the right arm of the wheelchair and his/her right arm lay across his/her lap.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 10)
Review of the care plan, dated 6/1/18 and last revised 3/11/19, showed no documentation
regarding right sided paralysis or right arm trough for the wheelchair.
8. Review of Resident #77’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Moderate cognitive impairment;
-Unable to ambulate;
-Extensive assistance needed for personal care and mobility;
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED]
-An order, dated 1/17/18, to administer [MEDICATION NAME] (diuretic) 20 mg;
-An order, dated 3/6/19, to apply tubi grips (compression stockings) to bilateral legs
daily for swelling.
Review of the care plan, dated 6/1/18 and last revised 3/11/19, did not address the
resident’s leg swelling.
9. During an interview on 5/17/19 at 10:30 A.M., the Director of Nursing said all care
plans should reflect the resident’s current status and goals. If a resident had issues
with depression, pressure ulcers, oxygen use, activities, restorative therapy, pain,
contractures, paralysis or [MEDICAL CONDITION], it should be on the care plan. The
interdisciplinary team was responsible for updating the residents’ care plans.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure resident
care plans reflected current needs by not updating them to include psychotic medication
use and interventions, failed to reflect lower leg [MEDICAL CONDITION] (swelling) and
lower leg wraps, specific and current wound treatments, failed to reflect the change in
wound treatments used and reflect the long term use of antibiotic as a [MEDICATION NAME].
The affected five of 35 sampled residents (Residents #8, #144, #60, #56 and #47). The
census was 177.
1. Review of Resident #8’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/1/19, showed the following:
-Cognitively intact;
-No mood issues;
-Verbal behaviors daily;
-Daily antipsychotic medication;
-[DIAGNOSES REDACTED].
Review of the electronic physician order [REDACTED].
Review of the admission care plan, dated 10/15/18, showed the following:
-Focus: The resident has a behavior problem related to brain damage and he/she refused lab
work frequently;
-Goal: The resident will have fewer episodes of behaviors by review date.
-Interventions: Explain all procedures to the resident before starting and allow time for
the resident to adjust to the changes, staff intervene as necessary to protect the rights

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
and safety of others, approach him/her in a calm manner, remove from situation and take to
an alternate location as needed, document if he/she refused to allow laboratory work to be
completed and notify his/her physician;
-The care plan did not address the use of [MEDICATION NAME] or possible side effects.
2. Review of Resident #144’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Required extensive assistance to total dependence on staff for all personal hygiene and
mobility;
-[DIAGNOSES REDACTED].
Review of the ePOS, dated 5/6/19, showed an order to apply ACE (used to reduce swelling
and improve circulation) wraps to bilateral (both) legs every morning and remove at
bedtime.
Observation on 5/13 at 2:39 P.M., 5/14 at 11:00 A.M., 5/15 at 8:20 A.M. and 12:58 P.M.,
5/16 at 6:42 A.M., 10:32 A.M. and 1:00 P.M. and 5/17/19 at 7:09 A.M., showed he/she sat in
his/her wheelchair, both legs swollen and ACE wraps applied to both legs.
Review of the care plan dated 8/11/18 and last revised 3/11/19, showed no documentation
regarding leg swelling or the application of ACE wraps to bilateral legs.
3. Review of Resident #60’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive staff assistance needed with bed mobility, hygiene, toileting and mobility;
-[DIAGNOSES REDACTED].>-Received hospice services;
-At risk to develop skin issues;
-Received turning and repositioning program and pressure reducing device to his/her chair
and bed.
Review of the ePOS, showed an order dated 5/11/19, to clean the left heel with normal
saline or wound cleanser. Apply Santyl ([MEDICATION NAME] ointment, used to remove dead
tissue from a wound) with calcium. Apply dry 4 x 4 gauze and wrap with kling
(self-adhering, conforming bandage). Change dressing daily and as needed (PRN).
Observation on 5/13/19 at 10:20 A.M., showed a bottle of wound cleanser and various
treatment supplies on the sink counter top in the resident’s room. The resident’s bed had
an air mattress set on firm and to normal pressure setting.
Review of the treatment administration record (TAR) dated 5/2019, showed an order dated
5/11/19 to clean the left heel with normal saline or wound cleanser. Apply Santyl with
calcium. Apply dry 4 x 4 gauze and wrap with kling. Change dressing daily and PRN.
Initialed as completed daily 5/11/19 through 5/16/19.
Review of the resident’s progress note dated 5/12/19, showed the resident completed
[MEDICATION NAME] (antibiotic) for bilateral heel wound infection on 5/14/19. The resident
was seen by the wound care physician weekly for heel wounds. Skin was intact except for
heel wounds.
Review of the undated care plan, showed the following:
-Problem: Risk for skin breakdown due to frequent incontinent episodes and had actual
impairment to the left heel, right outer heel and the left hip;
-Goal: The resident will remain with intact skin;
-Interventions: Assist and teach the resident to reposition him/herself PRN, pressure
ulcer assessment every three months (BRADEN scale, used to evaluate skin breakdown risk),
encourage the resident to turn every two hours to prevent breakdown, assist with
incontinence care, air mattress in place, keep him/her dry and clean, staff observe skin
during bathing and report any new areas to the nurse, nurse to perform weekly body checks.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-The care pan did not include the use of the antibiotic for the heel wound, did not update
the healed hip wound and did not include the wound care physician or ordered treatments.
4. Review of Resident #56’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive assistance with most activities of daily living (self care
activities);
-[DIAGNOSES REDACTED].
-At risk for presser ulcers (pressure injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure or friction);
-One unstageable presser ulcer (slough (dead tissue) is present, the actual base and
condition of the ulcer cannot be determined) with suspected deep tissue injury in
evolution.
Review of the resident’s (MONTH) 2019 POS, showed the following:
-An order, dated 4/30/19, to check [DEVICE] (vacuum assisted closure used to conduct
negative pressure wound therapy to promote healing) functioning every shift two times a
day for prevention;
-An order, dated 5/1/19, to apply [DEVICE] to left heel on Mondays, Wednesdays and
Fridays, suctioning at 120 millimeter of mercury (mmHg, a manometric unit of pressure) one
time a day for wound healing;
-An order, dated 5/3/19, for [MEDICATION NAME] (used to treat minor wounds and to help
prevent or treat mild skin infections) to right heel daily, one time a day for prevention.
Observations of the resident on 5/13 at 12:47 P.M., 5/14 at 2:00 P.M., 5/15 at 11:51 A.M.,
and 5/17/19 at 11:00 A.M., showed the resident up in his/her wheelchair. A clear tube
could be seen coming out of the resident’s left inflatable boot. The resident wore an
inflatable boot on his/her right foot as well. Both boots covered the resident’s feet and
extended up to his/her knees.
During an interview on 5/16/19 at 9:15 A.M. Registered Nurse (RN) L said the resident’s
right heel was mushy and they were using skin prep (protective barrier wipe) to treat it.
It was not open. The resident’s left heel was related to his/her diabetes, which they
believed was also causing the issues with the resident’s right heel. The resident did not
have any other wounds or treatments.
Review of the undated care plan, in use during the survey, showed the following:
-Problem: Potential/actual impairment to skin integrity related to fragile skin and
surgical wound. Impaired skin: pressure wound to coccyx (tailbone) and surgical wound to
left heel;
-Goal: Skin impairment will have no complications through the review date;
-Interventions included: Encourage good nutrition and hydration in order to promote
healthier skin, float heels while in bed as tolerated, pressure relieving and reducing
mattress and pillows to protect the skin while in bed;
-Staff did not update the care plan to show the resident’s coccyx wound healed;
-Staff did not update the care plan to show the use of a [DEVICE] to treat the left heel;
-Staff did not update the care plan to show treatments in place to prevent a pressure
wound to the resident’s right heel;
-Staff did not update the care plan to show the resident wore inflatable boots as a
preventative measure.
5. Review of Resident #47’s admission MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Extensive staff assistance needed for transfers, dressing, hygiene and toileting;
-Continent of bowel and bladder
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-Participating in a toileting program;
-[DIAGNOSES REDACTED].
-Received an antibiotic daily.
Review of the ePOS, showed an order, dated 2/8/19, for [MEDICATION NAME] (antibiotic) 500
mg. Take one tablet twice daily for a UTI and [MEDICATION NAME]-[MEDICATION NAME]
(antibiotic) 800-160 (combination drug) mg one tablet daily for a UTI. There was no stop
date noted on the ePOS.
Review of the progress notes, showed the following:
-On 5/14/2019 at 6:41 P.M., the resident continued on the antibiotics for [MEDICATION
NAME] use for UTI prevention. No signs or symptoms of adverse reactions. No fever was
noted. Fluids were encouraged.
-On 5/15/2019 5:47 A.M., the resident’s temperature was 98.2 degrees. He/she continued on
long-term [MEDICATION NAME] antibiotic for history of recurrent UTIs, no signs or symptoms
of adverse reactions noted. Oral fluids encouraged, aware of bowel and bladder needs and
toilets himself/herself with stand by assistance. No complaints of pain or discomfort. No
changes in mental status or behaviors.
Review of the undated care plan, showed no reflection of UTI history or antibiotic use for
[MEDICATION NAME] prevention for the UTI.
6. During an interview on 5/16/19 at 1:00 P.M., the Director of Nursing said the MDS
coordinators were responsible to update resident care plans to reflect the resident’s
current status. The care plans should include the current needs, treatments and wants of
the resident. Management had daily meetings and the MDS coordinators were updated at that
time of any changes in the residents. Care plan updates should be completed within 24
hours of the changes and the interdisciplinary team was responsible to ensure the care
plans were updated.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to administer
treatments as ordered (Residents #81, #51 and #5), failed to obtain orders for a
peripherally inserted central catheter (PICC, a thin, soft, long catheter (tube) that is
inserted into a vein. The tip of the catheter is positioned in a large vein that carries
blood into the heart and used to administer medication), code status and inflatable boots
(Residents #43, #44 and 56), failed to provide dietary supplements as ordered (Residents
#23 and #154), failed to clarify orders (Resident #94) and failed to apply medical
stockings as ordered (Residents #77 and #152). The census was 177.
1. Review of Resident #81’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/22/19, showed the following:
-Severe cognitive impairment;
-Limited staff assistance needed with hygiene;
-[DIAGNOSES REDACTED].
-Surgical wound treatment;
-Received ointments other than to the feet.
Review of the undated care plan, in use during the survey, showed the following:
-Problem: The resident picks at his/her skin, causing injuries. He/she picked at the top

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
of his/her head causing a wound;
-Goal: Interventions will reduce the picking behavior;
-Interventions: Assess the behavior patterns, intensity, and duration of the problem
behavior. Attempt to determine if this behavior is associated with particular events.
Assess for recent medication changes, changes in environment as possible causes. Consider
boredom or nervousness as possible causes of behavior. Anticipate and meet his/her needs
to attempt to control the behavior problem. Staff to provide assistance with washing
his/her hands as needed. Include him/her and/or responsible party in treatment plan.
Notify the physician of any significant changes with behaviors.
Review of the electronic physician order [REDACTED]. Change daily and as needed (PRN).
Scheduled during 7:00 A.M. to 7:00 P.M. shift.
Observations during the survey, showed on 5/13/19 at 10:37 A.M. and 1:53 P.M., a large
white dressing noted to the top of the resident’s head. The dressing did not have a date
or staff initials.
Further observations on 5/14/19, showed, from 7:44 A.M. through 9:02 A.M., the resident
sat at the breakfast table with the wound to the top of his/her head uncovered and
exposed. The resident ate at the table. Two other residents sat at the table with him/her.
Approximately 25 other residents sat in the dining room during the meal service. One nurse
and two aides were present during the meal service. No staff attempted to cover the
exposed wound.
During an interview on 5/14/19 at 10:29 A.M., Licensed Practical Nurse (LPN) C said the
facility used a wound care nurse and the wound care nurse applied all resident treatments.
If the wound dressing was missing or the resident pulled the treatment of [REDACTED]. Open
wounds should be covered before meals and not exposed. The resident, at times, removed the
dressing from the top of his/her head to scratch at the wound.
Further observations on 5/14/19, showed:
-At 11:28 A.M., and 1:01 P.M., the resident lay in his/her bed. He/she occasionally rubbed
the top of his/her head. The wound did not have a treatment in place;
-At 1:45 P.M., a dry dressing noted to the top of his/her head. The dressing dated 5/14/19
and initialed by staff.
Further observations on 5/15/19, showed:
-At 6:15 A.M., LPN C watched the resident walk past the nurses’ station and observed
his/her head. LPN C asked the resident if he/she was going into the dining room and the
resident replied yes. Staff failed to apply a dressing to the resident’s head. The wound
remained exposed with approximately six areas of dried blood or scratch marks noted to the
side of his/her head. Staff failed to cover the wound;
-From 7:19 A.M. to 8:50 A.M., the resident sat at the breakfast table. His/her head wound
remained uncovered with five dried blood marks noted to side of his/her head. Two nurse
aides remained in the dining room. Approximately 15 other residents sat in the dining room
for meal service. Staff failed to cover the open wound during the meal service;
-At 10:19 A.M., a dressing covered the resident’s head wound. Staff failed to date and
initial the treatment.
Review of the resident’s (MONTH) TAR, dated 5/2019, showed the following:
-An order, dated 3/29/19, to cleanse top of head with NS, mix triple antibiotic ointment
with collagen powder, apply [MEDICATION NAME]. Cover with a 4 x 4 gauze and secure with
tape. Change daily and PRN. Scheduled during 7:00 A.M. to 7:00 P.M. shift;
-Staff documented administration of the treatment 5/1/19-5/16/19.
During an interview on 5/16/19 at 12:45 P.M., the Director of Nursing (DON) said physician
orders [REDACTED]. Residents should not be in the main dining room with an uncovered
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
wound.
2. Review of Resident #51’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for most activities of daily living;
-Upper and lower extremity impairment on one side;
-Used manual wheelchair;
-Incontinent;
-No application of ointment or non surgical dressings other than to feet;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 3/1/19, showed no mention of skin issues to
bilateral lower extremities, goals or interventions for care.
Review of the resident’s POS, dated (MONTH) 2019, showed no order for topical treatment to
the resident’s bilateral lower extremities.
Review of the resident’s weekly skin observation tool, showed the following;
-5/1/19, no new skin issues;
-5/8/19, no skin issues;
-5/15/19, weekly skin assessment complete. No concerns. Skin was dry, warm, superficial
scratch noted to left posterior hand and bilateral shins. Resident had no concerns
regarding skin. Will continue to monitor.
Observations of the resident, showed the following:
-On 5/13/19 at approximately 10:00 A.M., the resident sat in a wheelchair with the lower
arms wrapped in sheep’s wool, wore short pants and had multiple scabs with redness on
his/her lower extremities;
-On 5/14/19 at 10:37 A.M., the resident sat in a wheelchair in his/her room and wore long
pants;
-On 5/14/19 at 10:50 A.M., a staff nurse said the sores on the resident’s legs were from
running into things and the resident picked at them;
-On 5/15/19 at 6:35 A.M., the resident sat in a wheelchair with the lower arms wrapped in
sheep’s wool and wore long pants;
-On 5/16/19 at 7:40 A.M., the resident sat at the dining table in a wheelchair with the
lower arms wrapped in sheep’s wool, wore short pants and had multiple scabs with redness
on both legs.
During an interview on 5/16/17 at 7:47 A.M., the resident said the padding had been on the
wheelchair for a while and the scabs on his/her legs were not new. The scabs hurt. Staff
put cream on them, but he/she did not scratch them.
During observation and interview on 5/17/19 at 9:00 A.M., the resident sat in a wheelchair
in his/her room as LPN B pulled up his/her pant leg to show multiple reddened and scabbed
areas on both legs. LPN B said when the resident’s legs were bad and the nurse
practitioner ordered triple antibiotic ointment and a dry dressing. The resident’s legs
clear up, then the areas came back again. He/she was not aware they were bad again, and
did not like the way they looked. LPN B would get an order for [REDACTED].
3. Review of Resident #5’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for most activities of daily living;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 4/22/19, showed the following:
-Problem: Reoccurring fluid filled blisters on scrotum and anal area;
-Goal: Intact skin, free of redness, blisters or discoloration by/through review date;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-Interventions: Administer multivitamin as ordered, educate resident, family and
caregivers, follow facility policies/protocols for the prevention/treatment of [REDACTED].
Review of the resident’s POS, dated (MONTH) 2019, showed the following:
-An order, dated 4/29/19, for Bactrim DS (antibiotic) tablet 800-160 milligrams (mg), give
one tablet by mouth in the morning for [MEDICATION NAME] (prevention);
-An order, dated 5/7/19, for [MEDICATION NAME] Solution (topical antibiotic) 1%, apply to
groin and buttocks topically two times a day for Hidradenitis Suppurativa (chronic skin
disease).
During an interview on 5/13/19 at 3:27 P.M., the resident lay on the bed and said he had
boils on his buttocks. They hurt and staff put a treatment on them.
Review of the resident’s progress notes, showed the following:
-5/14/19 at 3:20 P.M., infection note, resident continues Bactrim and [MEDICATION NAME]
topical indefinitely for Hidradenitis Suppurativa [MEDICATION NAME];
-5/15/19 at 8:05 A.M., infection note, resident is on observation for antibiotic therapy
related to [MEDICATION NAME];
-5/16/19 at 10:57 P.M., infection note, remains on Bactrim and [MEDICATION NAME] topical
antibiotic long term for Hidradenitis Suppurativa [MEDICATION NAME].
Review of the resident’s TAR, dated (MONTH) 2019, showed the following:
-[MEDICATION NAME] Solution 1%, apply to groin and buttocks topically two times a day for
Hidradenitis Suppurativa, A.M. and P.M.;
-A.M., initialed as done 5/8 through 5/14/19 and blank 5/15 through 5/17/2019;
-P.M., initialed as done 5/8 through 5/13/19 and blank 5/14 through 5/16/19, with no
documentation on the back of the TAR to explain why treatments were not completed.
During observation and interview on 5/16/19 at 2:00 P.M., the resident sat in a wheelchair
in his/her room and said the treatment to his bottom had not been done. The nurse said it
would be done when the resident lay down.
During an interview on 5/17/19 at 8:04 A.M., the resident sat in a wheelchair outside his
room and said no one did the treatment.
During an interview on 5/17/19 at 9:15 A.M., LPN B looked at the treatment order for
[MEDICATION NAME] Solution 1%, and said if the TAR was not initialed, the treatment had
not been done.
During an interview on 5/17/19 at 10:00 A.M., the DON said all physician’s orders
[REDACTED].
4. Review of Resident #43’s significant change MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE] and reentered on 5/1/19;
-Moderate cognitive impairment;
-Dependent on staff for all personal hygiene and mobility;
-Received hospice services.
Observation on 5/13/19 at 12:27 P.M., showed the resident lay in bed with his/her eyes
closed, both arms [MEDICAL CONDITION] (swollen) and a single lumen (one port) PICC line
inserted into his/her upper left arm. The dressing on the PICC read 5/1/19.
Review of the POS, dated 5/2019, showed no order for a PICC line, no orders for the care
of a PICC line and no intravenous medication.
Further observations of the resident on 5/14/19, at 10:09 A.M. and 5/15/19 at 6:28 A.M.,
showed the PICC line intact to the left upper arm and the dressing on the PICC, dated
5/1/19.
During an interview on 5/17/19 at 10:30 A.M., the DON said if a resident had a PICC line,
there should be orders for the line itself and the care of the line. The dressing should
be changed weekly and if it was not in use, it should be discontinued.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
5. Review of Resident #44’s annual MDS, dated [DATE], showed the following:
-Original admission date of [DATE] and reentered on 9/25/18
-Severe cognitive impairment;
-Extensive assistance with all personal care;
-Unable to ambulate;
-Propels self in wheelchair;
-[DIAGNOSES REDACTED].
Review of the POS, dated 5/1/19, showed the following:
-An order, dated 12/5/19, to administer [MEDICATION NAME] (blood pressure (B/P)
medication) 10 mg one tablet every morning and hold for systolic blood pressure (SBP, top
number) of less than 110 or diastolic blood pressure (DBP, bottom number) of 60 or below;
-No order for code status.
Review of the medical record, showed a facility code status form, signed and dated by the
resident on 2/19/19, for full code status.
Review of the TAR, dated 4/1/19 through 4/30/19 and 5/1/19 through 5/15/19, showed the
following:
-[MEDICATION NAME] administered daily as ordered;
-No documentation of BP.
During an interview on 5/17/19 at 10:30 A.M., the DON said all residents should have a
code status order on the POS along with a facility code status form, and they both should
match. She said it was the responsibility of staff to follow the physician’s orders
[REDACTED].
6. Review of Resident #56’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive assistance with most activities of daily living;
-[DIAGNOSES REDACTED].
-At risk for presser ulcers (pressure injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure or friction);
-One unstageable presser ulcer (Slough (dead tissue) is present, the actual base and
condition of the ulcer cannot be determined) with suspected deep tissue injury in
evolution.
Observations of the resident on 5/13/19 at 12:47 P.M., 5/14/19 at 2:00 P.M., 5/15/19 at
11:51 A.M. and 5/17/19 at 11:00 A.M., showed the resident up in his/her wheelchair. The
resident wore inflatable boots on his/her feet. Both boots covered the resident’s feet and
extended up to his/her knees.
Review of the resident’s medical record, showed the following:
-A signed code status sheet, dated 1/29/19, for full code;
-A (MONTH) 2019 POS, showed no order for the resident’s code status and no order for the
inflatable boots.
During an interview on 5/17/19 at 10:10 A.M., the DON said there should be an order for
[REDACTED]. The admissions coordinator gives the signed sheet to the admitting nurse who
then obtains the order. There should also be an order for [REDACTED].
7. Review of Resident #23’s annual MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Total dependence on staff for activities of daily living;
-Gastrostomy tube ([DEVICE]-a tube inserted through the abdomen that delivers nutrition
and hydration directly to the stomach);
-Upper and lower extremity impairment;
-Incontinent;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-No antidepressant medication administered in past 7 days;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 2/17/19, showed the following:
-Problem: Feeding tube, dependent with water flushes;
-Goal: Will maintain adequate hydration status, no signs or symptoms of dehydration
through review date, will be free of aspiration through review date;
-Interventions: Monitor weight weekly and as needed and registered dietician (RD) to
evaluate quarterly and as needed, monitor caloric intake, estimate needs.
Review of a nutrition note, dated 4/24/19, showed the following:
-Current weight of 179 pounds;
-Weight one month prior, 210 pounds;
-Weight three months and six months prior, 219 pounds;
-Significant weight loss noted but previous months could have been charted in error,
remains greater than recommended weight;
-Will monitor for decreased intake and further weight loss.
Review of the resident’s medical chart, showed a handwritten order, dated 5/3/19, on the
(MONTH) POS for a snack at bedtime.
Review of the resident’s POS, dated (MONTH) 2019, showed no order for a snack at bedtime.
Review of the resident’s medication administration record (MAR), showed no order for a
snack at bedtime.
During an interview on 5/17/19 at 9:09 A.M., the resident said no one asked if he/she
wanted a bedtime snack and he/she did not receive any.
During an interview on 5/17/19 at 10:00 A.M., the DON said an order written [REDACTED].
8. Review of Resident #154’s quarterly MDS, dated [DATE], showed the following:
-Cognitive pattern not assessed;
-Total dependence on staff for all activities of daily living;
-Three Stage III pressure ulcers (involves full-thickness skin loss potentially extending
into the subcutaneous (under the skin) tissue layer);
-Indwelling catheter;
-[DEVICE];
-[DIAGNOSES REDACTED].
Review of the resident’s POS, dated (MONTH) 2019, showed the following:
-Additional [DIAGNOSES REDACTED].
-An order, dated 12/27/18, for zinc sulfate (dietary supplement) 110 mg, give one tablet
via [DEVICE] in the morning.
Review of the resident’s medication administration record (MAR), dated (MONTH) 2019,
showed the following
-an order for [REDACTED].
-Staff initialed as given on 5/1/19;
-Staff initialed and circled on 5/2 and 5/3/19;
-Staff left the MAR blank on 5/4/19;
-Staff initialed and circled 5/6 through 5/8/19;
-Staff initialed as given on 5/9/19;
-Staff initialed and circled 5/10 through 5/12/19;
-Staff initialed as given on 5/13/19;
-Staff initialed and circled on 5/14 and 5/15/19;
-Staff left the MAR blank on 5/16/19 and initialed and circled on 5/17/19;
-The back of the MAR documented 5/2/19, not given resident in hospital. On 5/5, 5/10, 5/14
and 5/15/19, staff documented not available and not given.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
During an interview on 5/17/19 at 9:00 A.M., LPN B looked at the MAR and said the facility
had no problems getting medication from the pharmacy. Zinc was a stock medication and
should be in the facility. He/she should have been told if the medication medication was
not available so that it could be ordered. The physician should be notified the resident
did not receive the medication. A few minutes later, LPN B said no one told the supply
person they were out of zinc. The supply person would order it right away.
During an interview on 5/17/19 at 10:00 A.M., the DON said when a medication was not
available, the pharmacy should be contacted. A house medication such as zinc should be
available. If it was not available, nurse management or central supply should be notified
so it could be ordered. She was not aware the resident was not getting zinc.
9. Review of Resident #94’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE] and reentered on 1/16/19;
-No cognitive impairment;
-Dependent on staff for personal hygiene and mobility;
-[DIAGNOSES REDACTED].
Review of the POS, dated 5/1/19, showed an order, dated 4/22/19, to cleanse the exit of
the drain site with soapy water and reapply a dry dressing. The order did not indicate the
site of the drain or how often to cleanse the exit site.
Review of the care plan, in use during the survey, showed no documentation regarding a
drain.
During an interview on 5/17/19 at 10:30 A.M., the DON said the orders on the POS should be
specific and the order should include the site of the drain and the frequency the order
should be carried out.
10. Review of Resident #77’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Moderate cognitive impairment;
-Unable to ambulate;
-Extensive assistance needed for personal care and mobility;
-[DIAGNOSES REDACTED].
Review of the POS, dated 5/1/19, showed an order, dated 3/6/19, to apply tubi-grips
(compression stockings to prevent swelling) to bilateral legs in the morning and remove at
bedtime.
Review of the care plan, dated 8/11/18 and last reviewed on 3/11/19, showed no
documentation regarding leg swelling or the use of tubi-grips.
Observation and interview on 5/13/19 at 11:51 A.M., showed the resident sat in the
wheelchair with swelling noted to both legs and he/she wore short socks and no tubi grips.
He/she said prior to his/her arrival to the facility, he/she always wore compression
stockings which helped with the swelling in his/her legs.
Observations on 5/14/19 at 10:01 A.M., 5/15/19 at 11:29 A.M. and 1:15 P.M. and 5/16/19 at
1:23 P.M., showed the resident sat in a wheelchair. He/she did not have tubi-grips on
his/her legs.
11. Review of Resident #152’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive staff assistance needed for hygiene, dressing and toileting;
-[DIAGNOSES REDACTED].
Review of resident’s (MONTH) 2019 ePOS, showed an order dated 5/24/18 for [MEDICAL
CONDITION]-embolic deterrent (TED, anti-embolism stockings used to improve circulation in
the lower legs and prevent blood clots) hose. Apply TED hose daily in the morning and
remove at bedtime.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
During an observation and interview on 5/13/19 at 1:10 P.M., CNA D prepared to provide
personal care to the resident. CNA D removed the resident’s pants with no TED hose noted
to either lower leg. CNA D said he/she had not been told the resident had to wear TED
hose. The nurse would have informed him/her if the resident needed TED hose.
Observations during the survey, showed the resident did not wear ordered TED hose during
the following times:
-On 5/14/19 at 7:50 A.M., 10:46 A.M., 11:50 A.M. and 1:01 P.M.;
-On 5/15/19 at 9:20 A.M., 10:18 A.M. and 11:00 A.M.
During an interview on 5/16/19 at 12:45 P.M., the DON said physician orders [REDACTED].

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to provide and
ensure appropriate perineal (peri-care, cleansing the front of the hips, between the legs
and buttocks) care to two of three perineal care observations (Residents #77 and #152).
The facility also failed to provide meal service set up to one of 35 sampled residents
(Resident #58). The census was 177.
1. Review of Resident #77’s annual Minimum Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/23/19, showed the following:
-Moderate cognitive impairment;
-Extensive assistance required for all personal care and mobility;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 5/15/19 at 9:03 A.M., showed Certified Nurse Aide (CNA) A entered the
resident’s room, washed hands and donned gloves. He/she removed the wet with urine brief,
applied soap to a wet cloth and cleansed the genital area. He/she did not cleanse the
urinary meatus and did not rinse the genitals. He/she dressed the resident in a clean
brief, washed his/her hands and left the room.
During an interview on 5/15/19 at approximately 9:10 A.M., CNA A said if a man had been
circumcised it was not necessary to clean the urinary opening, and he/she did not feel the
need to rinse the genital area because he/she applied the soap to the cloth and not in the
water.
During an interview on 5/17/19 at 10:30 A.M., the Director of Nursing (DON) said it did
not matter if a man was or was not circumcised, the meatus needed to be cleansed
regardless and always rinsed after using soap.
2. Review of Resident #152’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive staff assistance needed for hygiene, dressing and toileting;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the undated care plan, in use during the survey, showed the following:
-Problem: Occasional urine dribble;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 21)
-Goal: Will be clean dry and odor free;
-Interventions: Staff assist with toileting, provide proper incontinence care every two
hours and as needed.
During an observation and interview on 5/13/19 at 1:10 P.M., CNA D prepared to provide
peri care. He/she entered the resident’s room, washed his/her hands and applied double
gloves to his/her hands. The resident sat in his/her wheelchair at the bedside and
appeared asleep and leaned forward over his/her legs. CNA D asked the resident to stand
up. He/she pulled on the resident’s waist band and assisted the resident to stand by the
wheelchair. CNA D pulled down resident’s pants and the brief. CNA D sprayed peri cleanser
directly onto the the front of the resident’s groin. The resident jumped when the peri
spray cleanser was applied. CNA D used a wet wash cloth and cleaned the tip of the penis.
CNA removed the first layer of gloves and disposed of the gloves. He/she did not clean
down the shaft of the penis. CNA D sprayed peri cleanser directly onto the resident’s
buttocks. The resident jumped and startled. CNA D obtained a wet towel from the sink basin
and cleansed in between the resident’s buttocks. He/she used the dried end of towel and
patted the buttocks off. He/she obtained a clean brief, opened the brief and laid it
across the resident’s bed. He/she squeezed barrier ointment directly onto the brief, and
used the brief to pat the ointment onto the resident’s buttocks. He/she said he/she
applied the ointment onto the brief to save on glove use and prevent the change of gloves.
CNA D applied and secured the brief into place.
During an interview on 5/16/19 at 12:45 P.M., the DON said the CNAs should pull back the
foreskin of a male when providing peri care on a male. Peri spray should not be applied
directly to the skin, the cleanser is cold and may startle a resident if applied to the
skin directly. Ointment should be applied with use of gloved hands, using a clean brief is
not an appropriate way to apply ointments to the skin.
Review of the facility’s perineal/incontinence care policy dated 1/1/2014, showed the
following:
-Purpose: To provide cleanliness and comfort to the resident, prevent infection and skin
irritation and observe the condition of the skin;
-Procedure: For male residents, retract the foreskin if the male is uncircumcised then
clean the tip of the penis using a circular motion starting at the urethra (opening into
the bladder) and work in an outward fashion. The penis shaft, scrotum and rectal area
should be cleaned and rinsed as well.
3. Review of Resident #58’s annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance required for most activities of daily living;
-Supervision with set up only required for eating;
-[DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (TBI-a blow to the head or a penetrating
head injury that disrupts the normal function of the brain) and depression.
Review of the resident’s physician order’s sheet (POS), dated (MONTH) 2019, showed the
resident had additional [DIAGNOSES REDACTED].
Review of the resident’s care plan, updated on 3/8/19, showed the following:
-Problem: Requires moderate to maximum assist with activities of daily living due to head
injury/motorcycle accident when teenager;
-Goal: Will maintain current functional level and resident will be appropriately groomed,
dressed and bathed with assist;
-Interventions: Monitor at meals and provide set up assist such as cutting up food as
needed.
Review of the resident’s therapy screening form, dated 3/4/19, showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 22)
-Difficulty grooming, toileting and feeding;
-Reduced upper and lower extremity functioning;
-Therapy evaluation recommended occupational therapy.
Observation on 5/15/19 at 6:50 A.M., showed the resident sat in a wheelchair at the dining
room table, leaned to the right with his/her head nearly rested on the chair arm and used
his/her left hand to pull on his/her contracted right hand.
During an interview on 5/15/19 at approximately 12:35 P.M., a visitor said he/she came
every day, sat at the table with the resident and the resident was supposed to have
someone help him/her at meals, but had not had help. Staff were not reliable and the
resident spilled food all over him/her self.
Further observations of the resident, showed the following:
-On 5/15/19 at 12:37 P.M., the resident sat in a wheelchair at the dining room table,
leaned to the right with his/her head nearly rested on the chair arm. A divided plate
contained a whole piece of lasagna and sat in front of him/her. The resident held a fork
in his/her left hand, tried to feed him/herself the lasagna and knocked a cup of lemonade
off the table onto the floor. The resident pushed him/herself back away from the table and
strained to reach with his/her left hand the paper placemat on the table to cover the
large spill on the floor at his/her feet. As the resident sat in the wheelchair away from
the table, a dietary aide filled a large Styrofoam cup with lemonade, put a lid and straw
on it and placed it on the table in front of the resident, but out of his/her reach;
-On 5/15/19 at 12:47 P.M., a dietary aide pushed the resident’s chair back to the table.
The resident tried to feed him/herself again with the fork, put the fork down and picked
up a large piece of lasagna with his/her left hand and put it in his/her mouth. CNA F sat
down at the table, cut up the lasagna, applied a clothing protector and gave the resident
a spoon. The resident began to feed him/herself the lasagna with the spoon;
-On 5/16/19 at approximately 7:25 A.M., the resident sat at the table and a divided plate
contained a whole omelette and whole muffin. A bowl of cereal with milk sat on the table
with no spoon and the resident had no drinks. The resident picked up the whole muffin with
his/her left hand and brought it to his/her mouth. At 7:33 A.M., CNA F sat next to the
resident, asked if he/she wanted a drink, got up and walked to the back of the dining room
and came back with a cup and a clothing protector. CNA F left the table again, walked to
the back of the dining room and came back with a straw. At 7:39 A.M., CNA F pushed the
resident from the dining room in the wheelchair.
During an interview on 5/17/19 at 8:14 A.M., occupational therapist (OT) E said the
resident needed minimum to moderate assist of 25% including set up with meals. Set up
consisted of cutting up food, opening packets, putting condiments on and making sure the
plate was ready to go. The resident liked to be as independent as possible.
During an interview on 5/17/19 at 10:00 A.M., the DON said meal set up included cutting
food up, placing drinks within reach, buttering bread and making sure the resident’s plate
was available to them. It was not appropriate for the resident to pick lasagna up with
his/her hands.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure safe

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Few

(continued… from page 23)
transfer techniques for two of three observed resident transfers. This practice placed the
residents at risk for falls or injuries during transfers. This affected one expanded
sample resident (Resident #112) and one of 35 sampled residents (Resident #152). The
census was 177.
1. Review of Resident #112’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/9/19, showed the following:
-admitted on [DATE];
-Moderate cognitive impairment;
-Total assistance of two staff with all transfers;
-Not steady during transfers without staff assistance;
-Received hospice services;
-[DIAGNOSES REDACTED].
Review of the admission care plan, dated 4/9/19, showed no transfer status.
Review of the hospice coordinated care plan, dated 3/3/19, showed the resident needed
total assistance with all transfers.
During an observation and interview on 5/15/19 at 6:38 A.M., Certified Nurse Aides (CNA) G
and H entered the resident’s room. The resident lay fully dressed in his/her bed. CNA G
said the resident normally used a stand-up lift (mechanical lift ideal for transferring
patients who are partially weight bearing) for all his/her transfers. The lift was
unavailable and in use by another aide on the unit. CNA G and H did not want to wait for
the lift to become available since the resident was ready to get up. CNA G wore a gait
belt around his/her waist and CNA H had no gait belt available. CNA H assisted the
resident to sit on the edge of his/her bed and placed the resident’s wheel chair next to
the edge of the bed. CNA G and H each placed an arm under the resident’s arm pits and
grabbed the back of the resident’s pant waist band. CNA G and H lifted the resident and
transferred him/her into the wheelchair. The resident did not assist or bear weight during
the transfer. CNA G said the resident also received hospice services and had been getting
weaker. He/she did not stand well or bear his/her own weight well anymore. CNA G said
he/she did not apply the gait belt to the resident because there were two aides for the
transfer and he/she did not feel the gait belt was needed. He/she was taught that a gait
belt was only needed with a one person transfer and did not think lifting a resident under
the resident’s arms or using the pants could be unsafe. CNA H said he/she had never been
trained to use a gait belt and had been a CNA for several years. Both CNA G and H said
they did not wait for the mechanical lift because it was in use when the resident was
ready to get up. They were supposed to get the resident up before the end of their shift
and waiting for the lift would have delayed their assignments. Aides report to each other
how a resident is transferred and the information is also included on the resident’s
Kardex (paper care reporting form), and the charge nurse will inform the aides if there is
a change.
During an interview on 5/15/19 at 6:44 A.M., Licensed Practical Nurse (LPN) I said the
resident was admitted about a month ago. The resident received hospice services and used a
mechanical lift for all transfers since admission. The resident had become weaker since
admission. If a resident used a mechanical lift, then the CNAs should always use the
mechanical lift. Anytime an aide transfers a resident, either a one person or a two person
lift, a gait belt should be used without exception. If the resident was supposed to be
transferred with a mechanical lift, that is what should be used. The staff should wait for
a lift to be available. It was not acceptable to use another form of transfer unless
approved. If a two person lift was used, a gait belt should always used to help steady the
resident from falling and maintain safety. Transfer status was written on the resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Few

(continued… from page 24)
Kardex form and should be on the resident’s care plan.
Review of the resident’s Kardex form dated 3/29/19, showed no transfer status.
2. Review of Resident #152 quarterly MDS dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive staff assistance needed with dressing, hygiene and toileting;
-One staff assistance needed with transfers;
-[DIAGNOSES REDACTED].
-Received hospice services.
During an observation and interview on 5/15/19 at 11:04 A.M., the resident slept in
his/her bed. CNA K woke the resident and explained it was lunch time and time for the
resident to get up. The resident opened his/her eyes, mumbled and fell back to sleep. CNA
J woke the resident a second time and assisted the resident to sit on the side of the bed.
The resident appeared sleepy and leaned over toward the side. CNA J supported the
resident’s side, and assisted him/her to sit up. CNA K pulled the resident’s wheel chair
next to the bed and applied a gait belt to the resident’s waist. CNA J and K used the gait
belt to assist the resident to stand. The resident did not bear any weight and his/her
arms hung loosely at his/her side. The resident’s right arm hung loosely behind him during
the transfer and drug behind him/her against the back of the wheel chair and hit the right
side of the wheel chair arm. Neither CNA supported the resident’s arm during the transfer.
CNA J said the resident used to walk a few weeks ago but had been getting weaker recently.
The resident received hospice services. The resident did not bear any weight during the
transfer and appeared more tired than usual. If a resident did not bear weight, the
resident should probably be a mechanical lift. Neither CNA knew how to change the transfer
status. CNA K pushed the resident into the unit dining room and provided juice to the
resident at the table. The resident consumed the juice. Neither CNA notified the charge
nurse of the resident’s arm hitting the wheel chair arm or the change in the resident’s
transfer status.
Review of the resident’s Kardex, showed the resident walked in the unit and needed
supervision to assist of one for transfers.
3. Review of the facility’s undated gait belt transfer policy, showed the following:
-Standard: Gait belts are provided to assist staff to safely transfer or ambulate
residents;
-Policy: Gait belts should be utilized for all residents for manual transfers unless
otherwise noted in the care plan.
4. During an interview on 5/16/19 at 12:45 P.M., the Director of Nursing said gait belts
should always be used for non mechanical lift transfers. If a resident was designated as
using a mechanical lift for transfers, staff should use a mechanical lift. Each wing and
unit had multiple mechanical lifts available for use. If a resident had a change in
condition or appeared weaker or more tired, the aides should notify the charge nurse for
an assessment. If a resident appeared more tired, the aides should allow the resident to
rest and offer a room tray or attempt to get the resident up closer to the meal service.
The resident’s transfer status should be listed on the Kardex and on the care plan.
Transferring a resident improperly could increase the risk for falls or injury.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain proper
placement and privacy of one resident’s (Resident #59’s) indwelling urinary catheter (a
tube inserted into the bladder for purpose of continual urine drainage) and two supra
pubic (SP, a small rubber tube inserted through the lower abdomen in to the bladder to
drain urine) catheters for two residents (Residents #94 and #154). Staff allowed the
urinary drainage bags to rest on the floor, staff did not intervene when there were kinks
in the tubing preventing proper drainage and staff did not cover a drainage bag with a
privacy cover. The facility identified six residents as having urinary catheters and of
those six, problems were found with three. The sample size was 35. The census was 177.
1. Review of Resident #59’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/9/19, showed the following:
-Severe cognitive impairment;
-Dependent on staff for all personal care and mobility;
-Incontinent of urine;
-[DIAGNOSES REDACTED]. Symptoms can include overflow incontinence, frequency, urgency,
urge incontinence, and retention), stroke and dementia.
Review of the care plan, dated 12/2/16 and last revised on 2/7/19, showed the following:
-Problem: Resident has an indwelling catheter due to a [DIAGNOSES REDACTED].
-Goal: Will remain free from catheter related trauma;
-Interventions: Check tubing for kinks each shift, monitor for and report to the physician
any burning, pain, blood tinged urine, no output, foul smelling urine, fever, chills
and/or mental status changes.
Review of the physician’s orders [REDACTED].
-An order, dated 2/6/19, to maintain the indwelling catheter with 16 French (FR, size of
the catheter) 5 cubic centimeter (cc) (size of the plastic bulb that holds the catheter in
place) and change monthly;
-An order, dated 2/6/19, to cleanse the catheter insertion site with soap and water twice
a day.
Observations of the resident, showed the following:
-On 5/14/19 at 8:27 A.M. and 10:17 A.M., the resident sat in his/her room in a wheelchair,
visible from the doorway. The catheter drainage bag hung on a bar under the chair with no
privacy cover and contained approximately 200-300 cc of urine in the bag;
-On 5/14/19 at 1:35 P.M., the resident sat in a wheelchair at the dining room table. The
urinary drainage bag hung under the wheelchair with no privacy bag and visible urine in
the bag;
-On 5/15/19 at 6:17 A.M., the resident sat in a wheelchair in his/her room with his/her
eyes closed. The catheter tubing exited from the cuff of his/her slacks and the drainage
bag lay on the floor beneath the foot pedal of the wheelchair with urine visible in the
bag.
-On 5/15/19 at 8:17 A.M. and 12:20 P.M., the resident remained in the wheelchair, the
catheter bag hung on the side of the chair and the lower third of the bag rested on the
floor. The bag held approximately 200 cc of urine;
-On 5/16/19 at 6:44 A.M., the resident sat in the wheelchair across from the nurse’s desk.
The catheter bag hung under the chair with no privacy bag and urine visible in the bag;
-On 5/17/19 at 7:05 A.M., the resident sat in a wheelchair in his/her room. The catheter
tubing exited from the cuff of his/her slacks, the bag hung on a bar under the chair and
the lower half of the bag lay on the floor. The bag had a blue flap over the front of the
bag.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)

2. Review of Resident #94’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE] and reentered on 1/16/19;
-No cognitive impairment;
-Dependent on staff for personal hygiene and mobility;
-[DIAGNOSES REDACTED].
Review of the care plan, in use during the survey, showed the following:
-Problem: Requires SP catheter due to a [DIAGNOSES REDACTED].
-Goal: Will not have any injuries or discomfort from catheter usage;
-Interventions: Assess for pain and discomfort, avoid pulling on catheter tubing, change
catheter monthly and as needed (PRN), dependent on staff for catheter care, empty catheter
bag prior to transfers, empty and measure output every shift, keep catheter bag below the
level of the bladder, give good catheter every shift, monitor for and report to the
physician any burning, pain, blood tinged urine, no output, fouls smelling urine, fever,
chills and/or mental status changes and position the catheter bag away from the room door.

Observations of the resident, showed the following:
-On 5/13/19 at 10:41 A.M., the resident lay in bed. The catheter drainage bag, not covered
by a privacy bag, hung on the bed frame visible from the door. The bag contained
approximately 100 cc of urine;
-On 5/14/19 at 7:47 A.M., the resident lay in a low bed. The catheter bag, not covered
with a privacy bag, hung from the bed frame and was visible from the hallway. The bag lay
on the floor, half-way under the bed and contained an undetermined amount of urine;
-On 5/14/19 at 10:18 A.M., the resident remained in bed on his/her back and the catheter
drainage bag, not covered with a privacy bag, hung on the bed frame. The bottom third of
the bag rested on the floor. The bag contained approximately 300 cc of urine;
On 5/15/19 at 8:16 A.M., the resident lay in bed and the uncovered catheter drainage bag
hung from the bed frame. The bag contained approximately 500 cc of urine and the lower
half of the bag rested on the floor;
-On 5/16/19 at 6:40 A.M., the resident lay in bed and the uncovered urinary drainage bag
lay on the floor.
3. Review of Resident #154’s quarterly MDS, dated [DATE], showed the following:
-Cognitive pattern not assessed;
-Total dependence on staff for all activities of daily living;
-Three Stage III pressure ulcers (involves full-thickness skin loss potentially extending
into the subcutaneous (under the skin) tissue layer);
-SP catheter;
-Gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach to provide
hydration, nutrition and medications);
-[DIAGNOSES REDACTED].
Review of the resident’s medical chart, showed the following:
-An order, dated 3/25/2019, for [MEDICATION NAME] (antibiotic) 500 milligrams (mg) by
[DEVICE] for 7 days for infection;
-A nurses’ note, dated 3/30/19, admitted to hospital for urinary tract infection [MEDICAL
CONDITION] and fever;
-An order, dated 4/15/19, for Linezolid (antibiotic) 600 mg., via [DEVICE] twice daily for
infection until 4/28/19.
Review of the resident’s care plan, updated on 4/22/19, showed the following:
-Problem: SP catheter;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
-Goals: Will be/remain free from catheter-related trauma through review date;
-Interventions: Check tubing for kinks frequently every shift.
Review of the resident’s POS, dated (MONTH) 2019, showed an order, dated 4/16/19, to
maintain SP catheter, 18 FR 10 cc bulb, catheter to straight drain.
Observation of the resident, showed the following:
-On 5/15/19 at 6:36 A.M. and 9:20 A.M., the resident lay in bed with a urinary drainage
bag inside a privacy bag and catheter tubing extended downward, looped back up and down
into the drainage bag, with a scant amount of urine in the tubing and no urine in the
collection bag;
-On 5/17/19 at 6:52 A.M. and 12:00 P.M., the resident lay in bed with the urine drainage
bag not in a privacy bag, visible to the hallway. Catheter tubing extended downward,
looped back up and down into the drainage bag, with approximately 5 to 6 inches of dark
amber urine unable to drain into the drainage bag.
4. During an interview on 5/17/19 at 10:30 A.M., the Director of Nursing (DON) said the
urinary drainage bag should always be below the level of the bladder. It should never lay
or rest on the floor and the tubing should be free of kinks to allow proper urine
drainage. She said these things were done to prevent infection and the bag should also
have a covering over the urine for privacy. She said the facility has urinary drainage
bags that have a cover over the side. If a resident was admitted from another facility or
hospital and did not have a bag with a privacy flap it was the responsibility of the staff
to change the bag.

F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to adequately
assess pain, record the degree and location of pain, re-evaluate the effectiveness of pain
medication, notify the physician of ineffective pain control and failed to follow a
physician’s orders [REDACTED]. This practice affected two residents (Resident’s #80 and
#88). The sample size was 35. The census was 177.
1. Review of Resident #80’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/20/19, showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-Extensive assistance required by staff for all personal care and mobility;
-Frequent severe pain that limits day to day activities;
-[DIAGNOSES REDACTED].
Review of the care plan, dated 3/8/19, showed the following:
-Problem: Chronic pain related to spinal stenosis;
-Goal: Will verbalize adequate pain relief or ability to cope with incompletely relieved
pain;
-Interventions: Administer [MEDICATION NAME] (pain relief medication) as ordered, give
[MEDICATION NAME] one half hour before treatment or care, anticipate need for pain relief
and respond immediately to any complaint of pain, monitor/document for side effects of
pain medication, observe for constipation, new onset or increased agitation, restlessness,
confusion nausea, vomiting or falls and report to the physician.
Review of the physician’s orders [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
An order, dated 3/8/19, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME])
10/325 milligrams (mg) one tablet every four hours as needed (PRN) for pain;
-An order, dated 3/9/19, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME])
5/325 mg two tablets every six hours PRN for pain;
-An order, dated 3/8/19, to administer [MEDICATION NAME] (treats nerve pain) 600 mg three
times a day for [MEDICAL CONDITION] (nerve damage causing weakness, numbness and pain);
-An order, dated 3/8/19, to administer [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 7.5 mg
twice a day for pain;
-An order, dated 3/8/19, to administer [MEDICATION NAME] (pain reliever) 50 mg one and one
half tablets every six hours PRN for pain.
Review of the medication administration record (MAR), dated 3/1 through 3/31/19, showed
[MEDICATION NAME] administered two times on 3/8/19 and a line drawn through the remaining
month with discontinue 3/8/19.
Review of the nurse’s notes, dated 3/9/19, showed the resident transferred to the hospital
due to severe pain.
Further review of the medical record, dated 3/9/19, showed a nurse’s note that the
resident returned from the hospital with a prescription for [MEDICATION NAME] (narcotic
[MEDICATION NAME]). A copy of a prescription located in the front of the chart, showed to
administer [MEDICATION NAME] 10/325 mg one to two tablets every four hours for three days
PRN for pain relief.
Review of the MAR, dated 3/1 through 3/31/19, showed the following:
-[MEDICATION NAME] administered 18 times from 3/11 through 3/26/19. No documentation on
the back of the MAR to indicate the location of or degree of the pain;
-[MEDICATION NAME] 5/325 mg administered four times between 3/13 and 3/21/19. No other
administrations recorded before 3/31/19 and no documentation on the back of the MAR to
indicate the location of or the degree of pain.
Review of the pharmacy controlled substance report, showed the following:
-[MEDICATION NAME] signed out as administered 51 times between 3/9 and 3/31/19;
-[MEDICATION NAME] signed out as administered 11 times between 3/9 and 3/15/19. No further
administrations recorded for (MONTH) 2019.
Review of the MAR, dated 4/1 through 4/30/19, showed the following:
-Received [MEDICATION NAME] 21 times and no documentation on the back of the MAR to
indicate the location of or degreed of pain;
-Received [MEDICATION NAME] 11 times and no documentation regarding the location of or
degree of pain.
Review of the nurse’s notes, showed he/she transferred to the hospital on [DATE] due to
back pain. He/she returned to the facility the same morning with a prescription for
[MEDICATION NAME] 10/325 mg one tablet every four hours for three days PRN for pain
relief.
Observation and interview on 5/13/19 at 9:50 A.M., showed he/she lay in bed on his/her
back with the head of the bed elevated 45 degrees. He/she complained of restricted
movement in all extremities and his/her neck. He/she said the pain in his/her neck and
back was constant and usually a 4 to 5 on a 0 to 10 scale. He/she said it was not unusual
for the pain level to reach an 8 before he/she received pain medication. He/she has been
transferred to the hospital on two occasions due to the discomfort.
Observation on 5/14 at 10:12 A.M. and 1:02 P.M. and 5/15/19 at 6:23 A.M., showed he/she
lay in bed on his/her back with the head elevated approximately 45 degrees, eyes closed.
Observation and interview on 5/15/19 at 10:02 A.M., showed he/she lay in bed and
complained of constant pain. He/she said the only medication that worked was the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
[MEDICATION NAME] but the effect would wear off and he/she again would suffer with the
discomfort.
Further observation on 5/15/19 at 1:19 P.M., showed he/she lay in bed with his/her eyes
closed.
Review of the MAR, dated 5/1 through 5/15/19, showed the following:
-Received [MEDICATION NAME] 15 times and no documentation regarding the location of or
degree of the pain;
-No recorded administrations of [MEDICATION NAME].
Review of the pharmacy controlled substance report, showed [MEDICATION NAME] administered
nine times between 5/11 and 5/14/19.
Review of the (MONTH) 2019 nurse’s notes, showed no documentation of the effectiveness of
the administered pain medications.
Observation and interview on 5/16/19 at 6:19 A.M., showed he/she lay in bed and said the
pain level was an eight and centered in his/her neck and shoulders. He/she said he/she
used to suffer with extreme leg pain but that had improved some, however the neck and
shoulder pain had not. He/she tried to ask for the pain medicine when the discomfort was a
level of six but staff often did not arrive with the medication until the level had
reached an eight. When that happened the level did not decrease below a six. He/she
recently went to the hospital again because of pain and was
sent back with a prescription for [MEDICATION NAME]. The [MEDICATION NAME] did not help at
all so he/she did not even ask for it. He/she took the [MEDICATION NAME] at times but felt
it was not effective either. He/she said it would be nice to just receive the medication
without having to ask for it, then maybe the pain would not become so severe.
During an interview on 5/16/19 at 8:35 A.M., Certified Medication Technician (CMT) T said
resident asked to be awakened when time for the pain medication. CMT T said he/she did not
do that and informed the resident that was not how PRN medications worked. He/she said the
resident refused to take the [MEDICATION NAME] or [MEDICATION NAME] saying they didn’t
work and very rarely will try the other medication. CMT T said the pharmacy would not send
the narcotic without a signed prescription from the physician. Sometimes it was difficult
to reach the physician, and sometimes the physician just did not send the script to the
pharmacy. The resident had to go the hospital on two different occasions due to pain and
the hospital sent him/her back with a few PRN [MEDICATION NAME].
Observation on 5/16/19 at 10:37 A.M., showed he/she lay in bed dozing.
Observation and interview on 5/17/19 at 7:17 A.M., showed he/she lay in bed watching TV,
in good spirits and said his/her pain level was a four.
During an interview on 5/17/19 at 10:30 A.M., the Director of Nursing (DON) said when a
nurse administered any PRN medication, the reason should be written on the back of the MAR
and the nurse should return about an hour later to see if the medication was effective. If
the medication is not effective the nurse should notify the physician to see if anything
else can be ordered. She said the [MEDICATION NAME] was discontinued on 3/8/19 because it
was not effective and at the same time obtained an order for [REDACTED]. She said for all
controlled medications, the pharmacy controlled substance report and the MAR should match.

2. Review of Resident #88’s admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive staff assistance with transfers, mobility, hygiene, dressing and
toileting;
-[DIAGNOSES REDACTED].
-Should pain assessment interview be conducted? Yes. Interview: No presence of pain.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
Review of the resident’s electronic medical record (EMR), showed the following:
-An order dated 3/14/19, for [MEDICATION NAME] (Used to treat minor aches and pains, and
reduces fever) 325 mg, take two tablets every 6 hour as needed for pain;
-An order dated 3/14/19 , for [MEDICATION NAME] 50 mg, give one tablet every eight hours
as needed for pain.
Review of the undated care plan, in use during the survey, showed staff did not address
the resident’s pain.
During an interview on 5/13/19 at 11:11 A.M., the resident said he/she had constant pain
in his/her right knee from arthritis. He/she would like to go home, but could not complete
therapy to get stronger due to the constant pain.
Further review of the resident’s medical record, showed the following:
-A hand written order by the resident’s physician on the hard copy of the POS, dated
5/10/19, for [MEDICATION NAME] to be given routinely every eight hours for pain;
-Staff did not document they received the order and did not transfer the order to the EMR;
-Review of the resident’s (MONTH) 2019 MAR, showed staff did not add the new order to the
MAR and did not administer the medication.
Review of the (MONTH) 2019 MAR, showed staff documented the resident received [MEDICATION
NAME] one time. Staff did not document the resident received any [MEDICATION NAME].
During an interview on 5/16/19 at 10:00 A.M., Registered Nurse (RN) L said staff should
add new orders in the EMR. He/She then looked in the EMR and verified the order from
5/10/19 had not been added. He/she did not know about the order.
During an interview on 5/16/19 at 1:05 P.M., the resident asked what could be done about
his/her knee pain. His/her pain was consistently at an 8 on a scale of 1-10.
Review of the resident’s EMR on 5/17/19, showed the following:
-An order, dated 5/16/19 for [MEDICATION NAME] 50 mg to be given every 8 hours for pain;
-No documentation staff had verified the order with the resident’s physician or made the
physician aware of the delay in administering the order.
Review of the resident’s (MONTH) 2019 MAR on 5/17/19 at 7:00 A.M., showed the following:
-The new order for the [MEDICATION NAME] with an order date of 5/16/19 and a start date of
5/17/19;
-Staff placed x’s in the administration boxes up until the evening of (MONTH) 17, 2019;
-Staff did not document the administration of any routine or as needed [MEDICATION NAME].
During an interview on 5/17/19 at 9:00 A.M., the resident said his/her pain was at a 7 on
a scale of 1-10.
During an interview on 5/17/19 at 10:10 A.M., the DON said a new physician’s orders
[REDACTED]. She would expect staff to document the missed order and that the physician was
notified. The resident should have begun receiving the [MEDICATION NAME] on 5/16/19.
During an interview on 5/17/19 at 1:30 P.M., the DON said she spoke with Nurse L regarding
the delay in administering the [MEDICATION NAME]. Nurse L said he/she set up the schedule
to begin on the evening of 5/17/19, because the resident had as needed [MEDICATION NAME]
available. The DON said she did not agree with Nurse L’s rationale.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide thorough assessments,
monitoring and ongoing communication with the [MEDICAL TREATMENT] center for a resident

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
who received [MEDICAL TREATMENT] (process for removal of waste and excess water from the
blood due to kidney failure). The facility identified four residents who received [MEDICAL
TREATMENT]. Of those four, two were selected for sample and issues were found with one
resident (Resident #88). The sample size was 35. The census was 177.
Review of Resident #88’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/27/19, showed the following:
-An admission date of [DATE];
-Cognitively intact;
-Required extensive staff assistance with transfers, mobility, hygiene, dressing and
toileting;
-[DIAGNOSES REDACTED].
-Special treatments received while a resident: [MEDICAL TREATMENT]
Review of the resident’s undated comprehensive care plan, in use during the survey, showed
the following:
-Problem: resident needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION];
-Goals: The resident will have immediate intervention should any signs/symptoms of
complications from [MEDICAL TREATMENT] occur through the review date;
-Interventions included: [MEDICAL TREATMENT] three times weekly per outside agency,
resident has a right chest central venous catheter (CVC, a type of access used for
[MEDICAL TREATMENT], monitor/document/report signs/symptoms of infection to access site,
do not draw blood or take blood pressure in arm with graft (a tube that is inserted into
the arm to connect an artery to a vein).
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
-An order, dated 3/29/19, for the resident to receive [MEDICAL TREATMENT] on Tuesdays,
Thursdays and Saturdays at a local [MEDICAL TREATMENT] center;
-An order, dated 3/29/19, to monitor CVC catheter for signs/symptoms of infection,
[MEDICAL CONDITION], and bleeding, notify [MEDICAL TREATMENT] center if there are any
abnormal findings;
-An order, dated 3/29/19, if CVC catheter is bleeding, apply pressure for 5-10 minutes,
then apply pressure dressing and notify physician;
-An order, dated 3/29/19, to complete and send [MEDICAL TREATMENT] communication form with
resident on scheduled [MEDICAL TREATMENT] days. Submit completed forms to Assistant
Director of Nursing (ADON);
-An order, dated 3/29/19, to verify emergency kit is at bedside.
Review of the resident’s (MONTH) 2019 treatment administration record (TAR), showed the
following:
-Staff wrote FYI next to each [MEDICAL TREATMENT] order;
-No documentation regarding the condition and/or appearance of the CVC catheter, and no
documentation of assessing the CVC catheter for signs/symptoms of infection, [MEDICAL
CONDITION] or bleeding.
Review of the facility’s [MEDICAL TREATMENT] binder, contained the [MEDICAL TREATMENT]
Communication Record, and showed the following:
-To be completed by nursing center:
-List of medication given within last 6 hours prior to sending to [MEDICAL TREATMENT]
center;
-Assessment of vascular access site;
-Time of last meal;
-Last weight at nursing center and date;
-Note any changes or information to resident’s condition;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
-To be completed by [MEDICAL TREATMENT] center:
-List of medications given during/after [MEDICAL TREATMENT] treatment (other than
[MEDICATION NAME] (anticoagulant));
-Weight pre and post treatment;
-Vital signs pre and post treatment;
-List of foods and amount the resident ate/drank;
-Special instructions/comments/orders, include any lab draws and tolerance to [MEDICAL
TREATMENT] procedure.
Further review of the [MEDICAL TREATMENT] communication binder, showed the following:
-A [MEDICAL TREATMENT] communication record, dated 5/14/19, showed both the nursing
facility and [MEDICAL TREATMENT] center information left blank;
-A [MEDICAL TREATMENT] communication record, dated 5/9/19, showed the record was
completed;
-A [MEDICAL TREATMENT] communication record, dated 4/26/19, showed both the nursing
facility and [MEDICAL TREATMENT] center information left blank;
-A [MEDICAL TREATMENT] communication record, dated 4/25/19, showed both the nursing
facility and [MEDICAL TREATMENT] center information left blank;
-A [MEDICAL TREATMENT] communication record, dated 4/25/19, showed both the nursing
facility and [MEDICAL TREATMENT] center information left blank;
-A [MEDICAL TREATMENT] communication record, dated 4/16/19, showed the record completed.
The [MEDICAL TREATMENT] center added: Watch CVC site for signs of infection and/or
bleeding;
-A [MEDICAL TREATMENT] communication record, dated 4/11/19, showed the nursing facility
information completed and [MEDICAL TREATMENT] center information left blank;
-A [MEDICAL TREATMENT] communication record, dated 4/9/19, showed the nursing facility
information completed and [MEDICAL TREATMENT] center information left blank;
-Staff failed to document consistent and complete documentation with the [MEDICAL
TREATMENT] center.
Review of the resident’s nurses notes, showed no documentation regarding nursing staff
providing an on-going, thorough assessments of the resident’s CVC catheter, no
documentation of assessing the resident’s condition before and/after [MEDICAL TREATMENT],
no documentation of assessing the site for for signs/symptoms of infection, [MEDICAL
CONDITION] or bleeding, and no documentation of communication between the [MEDICAL
TREATMENT] center or facility regarding the resident’s [MEDICAL TREATMENT] treatments.
During an interview with the resident on 5/16/19 at 1:10 P.M., the resident said staff do
not touch or look at his/her CVC catheter before or after his/her treatments.
During an interview on 5/17/19 at 10:10 A.M., the Director of Nursing said if a resident
receives [MEDICAL TREATMENT], she expected staff to check the site every shift for
infection and document it on the TAR. The resident’s weight and vital signs should be
taken pre and post [MEDICAL TREATMENT] and documented. They request the [MEDICAL
TREATMENT] center to complete this information on the communication form, but it has been
difficult to get the [MEDICAL TREATMENT] center on board. Facility staff should fill out
the outgoing communication form. If an order was on the POS, staff should not write FYI on
the orders on the TAR. If the TAR was blank, it meant staff did not document following the
order.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Observe each nurse aide’s job performance and give regular training.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Based on interview and record review, the facility failed to ensure each nurse aide had no
less than 12 hours of in-service education per year, based on their individual performance
review, calculated by their employment date rather than the calendar year. The facility
failed to ensure three of eleven randomly selected certified nurse aides (CNAs), employed
by the facility over one year, received the required annual 12-hour resident care
training. The census was 177.
Review of the CNA individual service records, showed the following:
-CNA M hired 8/24/2009, received eight and one half hours of in-service education;
-CNA N hired 5/17/2010, received nine and one half hours of in-service education;
-CNA O hired 6/5/2007, received eight hours of in-service education.
During an interview on 5/17/19 at 10:30 A.M., the Director of Nursing said she was aware
of the need for CNAs to receive 12 hours of resident-centered care inservicing every year.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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. The facility failed to properly document narcotic counts for the
controlled substances for four of the four facility medication carts. The facility census
was 177.
1. Review of the 100 wing controlled substance shift change count sheet (three shifts:
days, evening and nights), dated (MONTH) 2019, showed the following:
-On 5/1/19: Three packages of narcotics at 7:00 A.M.
-No nurse signatures for the 7:00 A.M. on-coming shift;
-No nurse signature or narcotic package counts for the 3:00 P.M. on-coming or off- going
shift;
-Three narcotic packages and no nurse signature noted for the 11:00 P.M. off-going shift;
-On 5/2/19: Three packages of narcotics at 7:00 A.M.;
-No on-coming nurse signature at 7:00 A.M.;
-No total narcotic package count or on-coming and off-going nurse signature for 3:00
P.M.;
-Three narcotic packages and no off-going or on-coming nurse signature for 11:00 P.M.;
-On 5/3/19: Three narcotic packages at 7:00 A.M.;
-No nurse signature off-going at 7:00 A.M.;
-No total narcotic package count or on-coming, off-going nurse signature at 3:00 P.M.;
-Three narcotic packages, no off-going nurse signature at 11:00 P.M.;
-On 5/4/19: No nurse signatures or total narcotic package counts at 3:00 P.M. or 11:00
P.M., on-coming or off-going;
-On 5/5/19: Three total narcotic packages at 7:00 A.M.,
-No off-going or on-coming nurse signatures at 11:00 P.M., 7:00 A.M., and 3:00 P.M.;
-On 5/6/19 and 5/7/19: no narcotic package count, or nurse signatures off-going or
on-coming for all shifts of 7:00 A.M., 3:00 P.M., and 11:00 P.M.;
-On 5/8/19: Three narcotic packages at 7:00 A.M.
-No off-going nurse signature at 11:00 P.M.,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 34)
-No total narcotic package count, on-coming or off-going nurse signatures at 7:00 A.M.,
3:00 P.M., and 11:00 P.M.;
-On 5/9/10, 5/10/19, 5/11/19, 5/12/19 and 5/13/19: No total narcotic package count, no
on-coming or off-going nurse signatures on any shift at 7:00 A.M., 3:00 P.M., or 11:00
P.M.;
-On 5/14/19: 15 total narcotic packages at 7:00 A.M.
-No on-coming or off-going nurse signatures at 7:00 A.M., 3:00 P.M., and no off-going
signature at 11:00 P.M.,
-On 5/15/19: 15 total narcotic packages at 7:00 A.M.
-No total narcotic package count or on-coming or off-going nurse signature at 3:00 P.M.
or 11:00 P.M.
2. Review of the 200 unit controlled substance shift change (two 12-hour shifts) check
sheet, showed the following:
-On 5/4/19: 11 total narcotic packages at 7:00 A.M.
-No total narcotic package count at 7:00 P.M.;
-On 5/5/19 and 5/6/19: No total narcotic package counts, no on-coming or off-going nurse
signatures at 7:00 A.M. and 7:00 P.M.;
-On 5/7/19: 13 total narcotic packages at 7:00 A.M.,
-No nurse signature off-going at 7:00 A.M. or 7:00 P.M.;
-On 5/14/19: 17 total narcotic packages at 7:00 A.M.,
-No total narcotic package count or off-going nurse signature at 7:00 P.M.
3. Review of the 300 wing controlled substance shift change (two 12-hour shifts)
count/check sheet, showed the following:
-On 5/1/19: 16 narcotic packages at 7:00 A.M.,
-No off-going or on-coming nurse signature at 7:00 P.M.;
-On 5/2/19: No total narcotic package count, on-coming or off-going nurse signatures at
7:00 A.M. or 7:00 P.M.;
-On 5/3/19: 16 narcotic packages at 7:00 A.M.,
-No off-going nurse signature at 7:00 P.M.,
-14 total narcotic package count at 7:00 A.M., and no off-going nurse signature at 7:00
P.M.,
-On 5/4/19: 16 narcotic packages at 7:00 A.M.;
-No off-going nurse signature at 7:00 A.M.
-On 5/6/19: 14 narcotic packages at 7:00 A.M.,
-No on-coming nurse signatures at 7:00 A.M.,
-No on-coming or off-going nurse signatures or total package count at 3:00 P.M., and
11:00 P.M.;
-On 5/7/19: No total narcotic package count, or nurse signatures at 7:00 A.M., 3:00 P.M.,
or 11:00 P.M.,
-On 5/8/19: 16 narcotic packages at 7:00 A.M.,
-No nurse signature off-going at 7:00 A.M.,
-No on-coming nurse signature at 7:00 P.M.;
-On 5/9/19: No total narcotic package count, on-coming or off-going nurse signature at
7:00 A.M.,
-On 5/10/19: 16 narcotic packages at 7:00 A.M.,
-No on coming nurse signature at 7:00 A.M. or 7:00 P.M.;
-On 5/11/19 and 5/12/19: No total narcotic package count, on coming or off going nurse
signatures at 7:00 A.M., or 7:00 P.M.;
-On 5/13/19: 16 narcotic packages at 7:00 A.M.,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 35)
-No off going nurse signature at 7:00 P.M.
4. Review of the 400 wing controlled substance shift change (two 12-hour shifts)
count/check sheet, showed the following:
-On 5/1/19: 15 narcotic packages at 7:00 A.M.,
-No on coming or off going nurse signatures at 7:00 A.M., or 7:00 P.M.,
-No total narcotic package count or on-coming or off-going nurse signature at 7:00 P.M.;
-On 5/2/19: No total narcotic package count, no on-coming or off-going nurse signatures
for 7:00 A.M., or 7:00 P.M.;
-On 5/3/19: No total narcotic package count or on-coming or off-going nurse signature at
7:00 A.M.,
-Total of 15 narcotic packages at 7:00 P.M., no off-going nurse signature;
-On 5/4/19: 15 narcotic packages at 7:00 A.M.,
-No on-coming nurse signature at 7:00 A.M.;
-No off-going nurse signature at 7:00 P.M.;
-On 5/5/19: 15 narcotic packages at 7:00 A.M.,
-No on-coming nurse signature at 7:00 A.M.,
-No off-going nurse signature at 7:00 P.M.;
-On 5/6/19: 15 narcotic packages at 7:00 A.M.,
-No on-coming nurse signature at 7:00 A.M.;
-No total narcotic package count or on-coming or off-going nurse signature at 7:00 P.M.;
-On 5/7/19: No total narcotic package count, or on-coming or off-going nurse signature for
7:00 A.M. or 7:00 P.M.;
-On 5/8/19: No total narcotic package count, or on-coming or off-going nurse signature at
7:00 A.M.;
-No off-going nurse signature at 7:00 P.M.;
-On 5/9/19: Total of 15 narcotic package count, no off-going nurse signature at 7:00 P.M.;
-On 5/10/19: Total of 15 narcotic package count at 7:00 A.M. and no on-coming nurse
signature.;
-No total narcotic package count or on-coming or off-going nurse signature at 7:00 P.M.;
-On 5/11/19 and 5/12/19: No total narcotic package count, on-coming or off-going nurse
signatures at 7:00 A.M., or 7:00 P.M.;
-On 5/13/19: No total narcotic package count or on-coming or off-going nurse signature at
7:00 A.M.;
-Total of 20 total narcotic packages and no off-going nurse signature at 7:00 P.M.;
-On 5/14/19: Total of 20 narcotic packages at 7:00 A.M., and no on-coming nurse signature;
-Total of 20 narcotic packages and no off-going nurse signature at 11:00 P.M.;
-On 5/15/19: No total narcotic package count or on-coming nurse signature at 7:00 A.M.
5. Review of the facility’s medication administration controlled substance policy, dated
2007, showed the following:
-Policy: Medications included in the Drug Enforcement Administration (DEA) classification
as controlled substance are subject to special handling, storage, disposal and record
keeping at the nursing care center, in accordance with federal and state laws and
regulations;
-Procedures:
-At each shift change, a physical inventory of controlled medications, as defined by
state regulation is conducted by two licensed clinicians and is documented on an audit
record;
-Current controlled medication accountability records and audit records are kept by the
nursing care center. When completed, audit and accountability records are kept on file
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 36)
according to state and federal regulations;
-Any discrepancy in a controlled substance medication count is reported to the Director
of Nursing (DON) immediately. The DON will investigate the discrepancy and research all
the records related to medication administration and the medication supply, including the
reconciliation (during the last shift count, receipt of a full medication container). A
thorough search in all drug storage areas, the resident room and other locations are made
to locate any missing container or medication supply;
-The DON documents irreconcilable discrepancies in a report to the administrator. If a
major discrepancy or pattern of discrepancies occurs or apparent criminal activity the DON
will notify the administrator, the consultant pharmacist and the pharmacy manager.
6. During an interview on 5/16/19 at 12:45 P.M., the DON said the Certified Medication
Technicians (CMT) and the nurses were responsible to complete the narcotic counts at the
change of shifts. Each off going shift is expected to count with the on coming shift. The
staff should initial the narcotic count sheets before leaving the building. Any missing
documentation on the narcotic count sheets should be immediately reported to the DON.
Staff should not leave the building if the count had not been completed or if a
discrepancy was noted.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to attempt a gradual dose
reduction (GDR) for a [MEDICAL CONDITION] medication for one resident (Resident #41) and
failed to obtain a new order, or discontinue the use of an as needed (PRN) [MEDICAL
CONDITION] drug beyond the 14 day limit for one resident (Resident #144). The sample size
was 35. The facility census was 177.
1. Review of Resident #41’s electronic physician order [REDACTED]. No reduction of the
medication was indicated in the POS since 9/15/18.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/27/19, showed the following:
-Moderate cognitive impairment;
-No mood or behaviors;
-Received hospice services;
-[DIAGNOSES REDACTED].
-No GDR completed;
-The physician had not documented that a GDR had been contraindicated.
Review of the undated facility care plan, showed the following:
Problem: The resident has impaired cognitive function related to dementia or impaired
thought processes;
Goal: The resident will maintain current level of cognitive function through the review
date;
Interventions: Ask yes/no questions in order to determiReview of the electronic physician
order [REDACTED]. No reduction of the medication was indicated in the POS since 9/15/18.
ne the resident’s needs, keep the resident’s routine consistent and try to provide

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
consistent care givers as much as possible in order to decrease confusion, the resident
needs supervision/assistance with all decision making and present just one thought, idea,
question or command at a time;
-The care plan did not address the use of antipsychotic medication
During an interview on 5/16/19 at 12:45 P.M., the Director of Nursing (DON) said [MEDICAL
CONDITION] or dementia is not an appropriate [DIAGNOSES REDACTED]. She expected the
pharmacy consultant to recommend a GDR for [MEDICAL CONDITION] medications. If the
physician did not want to attempt the GDR, the physician would need to provide
documentation for the refusal. The resident had not experienced any behaviors or outbursts
and is receiving hospice services. Staff should be monitoring behaviors for any resident
that takes [MEDICAL CONDITION] medications
2. Review of Resident #144’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Required extensive assistance to total dependence on staff for all personal hygiene and
mobility;
-[DIAGNOSES REDACTED].
Review of the care plan, dated 8/11/18 and last reviewed on 3/11/19, showed the following:
-Problem: Resident has behaviors at times. Gets frustrated with family and refuses to have
them visit;
-Goal: The resident will have fewer episodes by review date;
-Interventions: Anticipate and meet needs, assist in developing more appropriate methods
of coping and interacting, encourage to express feelings appropriately, praise any
indication of progress/improvement in behavior and social worker to meet with the resident
PRN to monitor for signs of coping or not coping with family issues.
-The care plan did not address the specific use of the PRN [MEDICATION NAME].
Review of the ePOS, dated 5/1/19, showed an order, dated 3/25/19, to administer
[MEDICATION NAME] (anti-anxiety) 0.5 mg one tablet every 12 hours PRN for anxiety.
Review of the Medication Administration Record [REDACTED].
Review of the MAR, dated 5/1 through 5/17/19, showed he/she did not receive any PRN doses
of [MEDICATION NAME].
During an interview on 5/17/19 at 10:30 A.M. the DON said she was aware of the 14 day
renewal for any PRN [MEDICAL CONDITION] drugs, and the [MEDICATION NAME] should have been
reviewed. If the resident was not taking the medication it should be discontinued.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to date insulin flex pens
(prefilled insulin pens) once opened, discard outdated insulin pens and ensure the
resident’s name appeared on the medication for 10 of 30 insulin pens and vials observed on
two of two medication carts. The census was 177.
1. Observation on [DATE] at 9:04 A.M., of the medication cart on 100 hall, showed the
following:
-A total of 18 flex-pens and two vials of insulin opened and in use;
-One Humalog (fast acting) insulin flex-pen, opened and dated [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
-One Humalog insulin flex-pen opened and dated [DATE];
-One Humalog flex-pen, opened and dated [DATE];
-Four [MEDICATION NAME] (short acting insulin) flex-pens with no date opened or date
expired;
-One [MEDICATION NAME] (long acting insulin) flex-pen in use with no resident name;
-One Humalog flex-pen opened with no date opened or expired.
During an interview on [DATE] at approximately 9:15 A.M., Licensed Practical Nurse (LPN) S
said that all flex-pens and vials should be dated and labeled with the resident’s name on
the medication. He/she said the vials and pens were good for 28 to 30 days and if one was
in use that was outdated, it should be destroyed.
2. Observation on [DATE] at 9:20 A.M. of the medication cart on 300 hall, showed the
following:
-A total of 10 flex-pens opened and in use;
-One [MEDICATION NAME] flex-pen opened with no date opened or expired.
3. During an interview on [DATE] at 10:30 A.M., the Director of Nursing said that all
insulin is good for 28 or 30 days. She said each of the flex-pens and vials should have
the resident’s name and the date opened. If one was out dated, it should be destroyed.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed to ensure food was stored and
served in a manner to prevent contamination by not covering desserts or the clean mixer
bowl after use, and serving oatmeal from a cart, table to table in the dining room, from
an uncovered pan. This deficient practice had the potential to affect all residents who
ate at the facility. The census was 177.
1. Observation of the kitchen showed the following:
-On 5/13/19 at 9:17 A.M. and 5/14/19 at 11:44 A.M., a sign on the wall behind the stand
mixer read clean mixer and slicer after use and cover. The mixer bowl sat underneath the
sign next to the mixer uncovered;
-On 5/14/19 at 11:24 A.M., a cart sat in front of the steam table and held three trays of
peach cobbler dessert cups. The top tray held five covered dessert cups, middle tray held
approximately 34 covered dessert cups and the bottom tray held 34 uncovered dessert cups.
The cart sat in the kitchen uncovered until meal service began at approximately 12:00 P.M.
2. Observation of the dining room on 5/17/19 at approximately 7:30 A.M. and 7:50 A.M.,
showed Dietary Aide (DA) P pulling a rolling cart with a metal pan of hot oatmeal and a
metal pan of another hot cereal on the top. Both pans were uncovered. DA P pulled the cart
to resident tables and dished out hot cereal. Numerous residents and staff walked past the
cart as DA P served from the uncovered pans. DA P served approximately 10 residents during
this time.
3. During an interview on 5/17/19 at approximately 1:00 P.M., the dietary manager said
they had served a lot of cakes this week so the mixer was in use a lot. It should be
covered when not in use. The peach cobbler cups that were covered were the ones going into
the hall carts. She was not aware the oatmeal was being served from a cart in the dining
room. Food items should be covered until served.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Arrange for the provision of hospice services or assist the resident in transferring to
a facility that will arrange for the provision of hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure and collaborate care
with resident elected hospice providers and failed to obtain a physician’s orders
[REDACTED]. Problems with coordinated plans of care were found with four of four residents
reviewed for hospice services (Residents #151, #41, #85 and #43). The census was 177.
1. Review of Resident #151’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/26/19, showed the following:
-Moderate cognitive impairment;
-Required extensive assistance from staff for activities of daily living such as transfers
and dressing and limited assistance for personal hygiene and toileting;
-[DIAGNOSES REDACTED].
-Special treatments received while a resident: Hospice.
Review of the resident’s medical record, showed the following:
-The (MONTH) 2019 electronic physician order [REDACTED].
-The progress notes, showed staff did not document hospice visits or communication;
-The hospice binder, showed no documentation of communication between the hospice provider
and the facility.
Review of the resident’s undated care plan, in use during the survey, showed the
following:
-Problem, received hospice care, with name, address and phone number of hospice agency
shown;
-Goals, symptoms will be controlled and will remain in facility until death;
-Interventions, contact hospice team for symptom management issues, refer to clinical
record for hospice team contact information, contact hospice nurse as needed regarding
home health aide referral for additional care needs, refer to hospice plan of care as
needed;
-Facility staff did not show a collaboration with hospice to show what specific services
would be provided.
2. Review of Resident #41’s quarterly MDS dated [DATE], showed the following:
-Moderate cognitive impairment;
-Extensive staff assistance needed for transfers, hygiene and toileting;
-Incontinent of bowel and bladder;
-Received hospice services;
-[DIAGNOSES REDACTED].
Review of the ePOS, showed no hospice orders.
Review of the resident’s hospice interdisciplinary plan of care review, dated 5/1/19,
showed the following:
-Start of hospice care: 10/3/18;
-Increased dependence on staff to complete daily care tasks;
-Weight loss of 14 pounds in a month;
-Hospice provided pull-ups, body wash, lotion, shampoo, bed, over the bed table, wheel
chair, bed and chair alarms and bedside fall mats.
Review of the undated care plan, in use during the survey, showed the following:
-Problem: Receiving hospice care related to stroke and difficulty swallowing. Name,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 40)
address and phone number of hospice agency shown;
-Goal: Symptoms will be controlled and he/she will remain in the facility until death;
-Interventions: The resident and the family will receive support and be prepared for
death, facility to contact hospice team for symptom management issues, refer to clinical
record for hospice team contact information, contact the hospice nurse as needed for
hospice health aide, referral for additional care needs and update the physician as needed
for change in condition and treatment plan changes;
-Facility staff did not show a collaboration with hospice to show what specific services
would be provided.
Review of the facility nurses’ notes, showed the following:
-On 5/2/2019 at 6:31 A.M., the resident remains on hospice. No complaint of any
discomfort, denies any pain. Slept well and staff will continue to monitor;
-On 5/8/2019 at 6:58 A.M., the remains on hospice. No change in condition observed. He/she
is alert and responds to verbal and physical stimuli.
3. Review of Resident #85’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance required for most activities of daily living;
-Incontinent of bowel and bladder;
-Had a condition or chronic disease that may result in a life expectancy of less than 6
months;
-Received hospice care;
-[DIAGNOSES REDACTED].
Review of the resident’s ePOS, dated (MONTH) 2019, showed the following:
-Additional [DIAGNOSES REDACTED].
-An order, dated 9/19/18, to admit to hospice care.
Review of the resident’s care plan, updated 3/26/19, showed the following:
-Problem: Received hospice care, with name, address and phone number of hospice agency
shown;
-Goals: Symptoms will be controlled and will remain in facility until death;
-Interventions: Contact hospice team for symptom management issues, refer to clinical
record for hospice team contact information, contact hospice nurse as needed regarding
home health aide, referral for additional care needs, refer to hospice plan of care as
needed;
-Facility staff did not show a collaboration with hospice as to what specific services
would be provided.
Review of the hospice comprehensive assessment and plan of care update report, dated
3/27/19, showed the following:
-Registered nurse visit one time weekly and three times as needed for symptom control;
-Home health aide visits two times weekly;
-Social worker visits two times within every 30 days and as needed for psychosocial needs;
-Spiritual care counselor visits one time every 30 day and tree times as needed for
spiritual needs;
-Nurse practitioner visits three times as needed and requested by team for advanced
directive discussion, pain and medication management.
4. Review of Resident #43’s significant change MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE] and reentered on 5/1/19;
-Moderate cognitive impairment;
-Dependent on staff for personal care and mobility;
-[DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
-Did not have a condition or chronic disease that may result in a life expectancy of six
months or less;
-Special services included hospice.
Review of the physician’s orders [REDACTED].
Review of the resident’s care plan, dated 2/6/19 and last updated on 5/4/19, showed the
following:
-Problem: admitted to hospice on 5/4/19;
-Goal: Resident will have symptoms controlled and will remain in the facility until death
and family will receive support and be prepared for death.
-Interventions: Contact hospice team for symptom management issues, refer to clinical
record for hospice team contact information, contact hospice nurse as needed regarding
home health aide referral for additional care needs, hospice social worker to assess for
needed hospice chaplain or psychologist visit for spiritual or grief issues and update
physician, include resident and his/her family in treatment plan.
in daily independent and or group activities;
-Facility staff did not show a collaboration with hospice to show what specific services
would be provided.
Review of the hospice/long term care coordinated task plan of care, dated 5/6/19, showed
the following:
-admitted to hospice on 5/4/19, with a [DIAGNOSES REDACTED].>-Hospice Registered Nurse
(RN) to visit every Tuesday and Thursday;
-Hospice Aide to visit every Sunday and Friday;
-Hospice social worker and chaplain to visit one to two times a month;
-Hospice did not show a collaboration with the facility to show what specific services
would be provided.
5. During an interview on 5/16/19 at 12:45 P.M., the Director of Nursing said that all
residents who receive hospice care should have current hospice orders. The orders should
include the selected hospice provider and hospice contact information. Resident #41 did
not have current hospice orders. The original orders must had been written on paper POS
and did not get carried over into the electronic system. The facility care plan should
show collaboration of care between hospice providers and the facility. The care plan
should reflect the current status of the resident.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

Based on observation, interview and record review, the facility failed to maintain
appropriate infection control by ensuring staff handled medications to prevent the
potential spread of infection during medication administration by staff who used bare
hands to administer medications to one resident (Resident #81) and failed to sanitize
hands during medication administration for two of four observations and failed to handle
soiled linen appropriately. The census was 177.
1. During an observation and interview on 5/14/19 at 8:20 AM, Certified Medication
Technician (CMT) Q prepared to administer morning medications to Resident #81. He/she
dispensed medications into a medication cup. One tablet dropped from the medication card
and fell on to the top of the medication cart next to the plastic medication cup. CMT Q
used his/her bare hand, picked up the tablet and placed the tablet into the medication cup

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265120

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST SOPHIA HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 42)
with the other ordered medications. He/she gave the medications to the resident. CMT Q
observed the resident take the medications, and he/she returned to the medication cart,
initialed the Medication Administration Record [REDACTED]. He/she did not sanitize his/her
hands in between resident medication administration. During an interview at that time, CMT
Q said he/she should not have handled the resident’s medication with his/her bare hands
and then administer the medication to the resident. He/she should have dispensed another
tablet from the resident’s medication card and destroyed the tablet that fell on to the
medication cart. Hands should be sanitized between resident medication administration.
2. During an observation and interview on 5/14/19 at 8:30 A.M., CMT R prepared to
administer morning medication to residents. CMT R administered two separate residents’
ordered medications. CMT R did not wash or sanitize his/her hands in between the
medication administrations of the residents. during an interview at that time, CMT R said
he/she forgot to sanitize his/her hands in between the medication pass of the residents.
Sanitizing hands would help prevent the spread of infection.
3. During an observation and interview on 5/15/19 at 6:15 A.M. to 6:50 A.M., certified
nurse aides (CNA) G and H preformed room checks on multiple residents. Both CNAs exited
the resident rooms with small black trash bags tied closed and filled with soiled linens.
The aides placed the bags directly on the unit floor outside the residents’ rooms. The
aides continued down the hallway and repeated this for a total of eight resident rooms. A
very strong urine odor was prevalent on the unit, and six residents were present in the
hallway. Eight trash bags lay on the unit floor outside of resident rooms. CNA H said that
the linens should be placed in the dirty linen hamper, but they could not find any
available before they started the rounds. They placed the soiled linen into the bags and
then on the floor outside each room. They would come back with the dirty linen cart and
pick up the soiled linens when they finished rounds.
4. Review of the facility’s medication administration general guidelines dated 5/2016,
showed the following:
-Policy: Medications are administered as prescribed, in accordance with good nursing
practice and principles;
-Medication Administration: Hands are washed with soap and water. Hands are washed with
soap and water after administration and with any other resident contact. Antimicrobial
sanitizer may be used in place of soap and water as allowed per state nursing regulation
and facility policy.
5. During an interview on 5/16/19 at 12:45 P.M., the Director of Nursing said when staff
administer medications, they should wash hands prior to beginning the medication pass.
Staff’s hands should be sanitized between resident administration. Medications should not
be handled with bare hands and should never be administered to a resident if the
medication had touched any surface. If a medication touched a surface, the staff should
dispose of that medication and dispense a new tablet for the resident. The staff should
also document the occurrence on the back of the MAR. Staff should wash hands, and sanitize
hands before and during medication pass to reduce the chance of infection. All of the
aides have access to dirty linen carts on each unit. The CNAs should obtain the dirty
linen carts prior to beginning rounds. Dirty linen should not be placed on the unit floors
at any time to prevent odor and reduce infections.