Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
55 residents
Based on a December 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Dec 8, 2025
Visit Reason
The inspection was conducted in response to complaints regarding the use and documentation of feeding tube administration and adequacy of nursing staff at the facility.
Complaint Details
Complaint #2679872 related to feeding tube administration and documentation; Complaint #2675273 related to inadequate nursing staff.
Findings
The facility failed to ensure proper administration and documentation of supplemental tube feeding for one resident, and failed to provide adequate nursing staff as determined by their facility assessment.
Deficiencies (2)
Failure to ensure one resident received supplemental liquid nutrition via gastrostomy tube as ordered and failure to document administration in the Treatment Administration Record.
Failure to provide enough nursing staff every day to meet the needs of every resident and to have a licensed nurse in charge on each shift.
Report Facts
Census: 55
Average daily census: 54.6
Certified Nurse Aides required: 6
Certified Nurse Aides required: 4
Certified Nurse Aides required: 3
Certified Medication Technicians required: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Interviewed regarding feeding tube administration and documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations for following physician orders and documentation |
| Administrator | Administrator | Interviewed regarding staff education and staffing schedule responsibility |
| Regional Director of Operations | Regional Director of Operations | Interviewed regarding auditing of resident Treatment Administration Records and staffing changes |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Aug 22, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to ensure proper respiratory care and failure to serve food at safe and appetizing temperatures.
Complaint Details
Complaint# 2587511 and 2587447. The complaint involved failure to ensure proper respiratory care and failure to serve food at safe temperatures.
Findings
The facility failed to ensure oxygen tubing and nebulizer masks were changed weekly for four residents and failed to provide oxygen therapy orders for one resident. Additionally, the facility failed to serve hot food at safe temperatures, with meals served below the required 120°F, risking resident safety.
Deficiencies (2)
Failed to ensure oxygen tubing and/or nebulizer mask and tubing were changed at least weekly for four residents and failed to provide orders for oxygen therapy for one resident.
Failed to ensure prepared food items were served at a safe and appetizing temperature, with hot food temperatures below 120°F upon service.
Report Facts
Facility census: 58
Food temperature: 91.5
Food temperature: 98
Required minimum food temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding oxygen therapy orders and responsibility for ensuring tubing changes and meal delivery monitoring | |
| Licensed Practical Nurse (LPN) A | Interviewed about responsibility for changing oxygen tubing and nebulizer masks | |
| Certified Nursing Assistant (CNA) B | Interviewed about meal service practices | |
| Administrator | Interviewed about meal delivery responsibilities and food temperature monitoring | |
| Dietary Staff Member [NAME] C | Interviewed about food plating and temperature standards |
Inspection Report
Routine
Census: 53
Deficiencies: 13
Date: Dec 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including employee background checks, resident notifications, care planning, safe resident transfers, medication administration, food service, staffing, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete required employee background checks prior to hire, failure to notify Ombudsman and residents about hospital transfers and bed hold policies, incomplete comprehensive care plans for residents, unsafe mechanical lift transfers, inaccurate bed rail assessments and lack of entrapment risk assessments, insufficient RN coverage, failure to post nurse staffing daily, medication errors including undated insulin pens and late medication administration, improper food storage and handling, incomplete Legionella water management plan, incomplete two-step TB testing for employees, failure to perform proper hand hygiene during resident care, and failure to implement Enhanced Barrier Precautions consistently.
Deficiencies (13)
Failure to check Employee Disqualification List and criminal background checks prior to hire for multiple employees.
Failure to notify Ombudsman for residents transferred to hospital and failure to provide written bed hold policy information.
Failure to develop and implement comprehensive person-centered care plans for residents.
Unsafe mechanical lift transfers with residents left suspended without two staff support and improper positioning of lift legs.
Failure to accurately assess bed rail use and complete entrapment risk assessments for residents using side rails or grab bars.
Failure to provide RN coverage for at least eight consecutive hours per day, seven days per week.
Failure to post nurse staffing information daily and maintain records for 18 months.
Medication error rate exceeded 5% due to undated insulin pens and late medication administration.
Failure to properly label and discard expired insulin medications and other food items; improper food storage and uncovered meals; ice scoop stored in ice; and lack of ice machine drain air gap.
Failure to develop and implement complete Legionella water management policies and procedures.
Failure to complete two-step purified protein derivative (PPD) testing for tuberculosis for multiple employees.
Failure to perform hand hygiene before and after glove use during perineal care for residents.
Failure to implement Enhanced Barrier Precautions including lack of staff education, signage, and PPE use for residents requiring precautions.
Report Facts
Facility census: 53
Medication error rate: 25.93
RN coverage hours: 7.55
RN coverage hours: 7.9
RN coverage hours: 7.83
RN coverage hours: 7.6
RN coverage hours: 7
RN coverage hours: 4.87
RN coverage hours: 6.83
RN coverage hours: 6.52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA I | Certified Nurse Aide | Named in background check and TB testing deficiencies |
| LPN J | Licensed Practical Nurse | Named in background check, TB testing, and medication administration deficiencies |
| Receptionist K | Receptionist | Named in background check and TB testing deficiencies |
| Social Services Director | Named in background check and Ombudsman notification deficiencies | |
| Certified Medication Technician L | Certified Medication Technician | Named in background check and medication administration deficiencies |
| Housekeeper N | Housekeeper | Named in background check and TB testing deficiencies |
| Nurse Aide B | Nurse Aide | Named in background check and TB testing deficiencies |
| Food Service Manager | Dietary Supervisor | Named in dietary qualifications and food service deficiencies |
| CMT O | Certified Medication Technician | Named in medication administration and insulin pen labeling deficiencies |
| CMT Q | Certified Medication Technician | Named in insulin pen labeling deficiencies |
| LPN G | Licensed Practical Nurse | Named in medication error and Enhanced Barrier Precautions deficiencies |
| NA A | Nurse Aide | Named in hand hygiene deficiency |
| CNA E | Certified Nursing Aide | Named in mechanical lift, hand hygiene, and Enhanced Barrier Precautions deficiencies |
| NA B | Nurse Aide | Named in mechanical lift, hand hygiene, and Enhanced Barrier Precautions deficiencies |
| NA C | Nurse Aide | Named in hand hygiene and Enhanced Barrier Precautions deficiencies |
| CNA R | Certified Nursing Aide | Named in hand hygiene and Enhanced Barrier Precautions deficiencies |
| LPN H | Licensed Practical Nurse | Named in Enhanced Barrier Precautions deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including background checks, TB testing, medication errors, hand hygiene, and infection control |
| Business Office Manager | Business Office Manager | Interviewed regarding background check processes |
| Administrator | Administrator | Interviewed regarding multiple deficiencies including staffing, background checks, medication errors, and infection control |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food service and dietary qualifications |
| Human Resources Manager | Human Resources Manager | Interviewed regarding dietary supervisor qualifications |
| Plant Supervisor | Plant Supervisor | Interviewed regarding Legionella water management and ice machine air gap |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding water system flushing and Legionella control |
| Registered Dietician | Registered Dietician | Interviewed regarding food service and dietary deficiencies |
| Shower Aide T | Shower Aide | Interviewed regarding ice scoop storage |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Oct 17, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure of facility staff to notify the responsible party and physician after an unwitnessed fall of a resident, and failure to complete neurological checks for residents who had unwitnessed falls.
Complaint Details
The complaint investigation found substantiated failures in notification and neurological monitoring after unwitnessed falls. Interviews with Licensed Practical Nurses, the Director of Nursing, the administrator, and a resident's family member confirmed the failures.
Findings
The facility failed to notify the physician and family of a resident's unwitnessed fall and failed to complete neurological checks for three residents who had unwitnessed falls, despite policies requiring notification and post-fall monitoring. Interviews with staff and family confirmed these failures.
Deficiencies (2)
Facility staff failed to contact one resident's responsible party and physician after an unwitnessed fall.
Facility staff failed to complete neurological checks for three residents who had unwitnessed falls.
Report Facts
Facility census: 54
Falls for Resident #3: 2
Falls for Resident #2: 3
Falls for Resident #1: 0
Neurological checks duration: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding fall notification and neurological checks; did not notify physician or family after resident's fall |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding fall notification and neurological checks; confirmed policy requirements |
| Licensed Practical Nurse F | Licensed Practical Nurse | Interviewed regarding neurological checks after falls |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for notification and neurological checks after falls |
| Administrator | Administrator | Interviewed regarding staff expectations for notification and neurological checks after falls |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 1
Date: Jul 1, 2024
Visit Reason
The inspection was conducted to evaluate the nursing facility's compliance with professional standards of quality, specifically focusing on post-fall neurological checks and documentation for residents who experienced unwitnessed falls.
Findings
The facility failed to complete the required 72-hour neurological checks and fall follow-up documentation for three sampled residents who had unwitnessed falls. Interviews with nursing staff and administration confirmed the expectation for these checks and documentation, but they were not completed.
Deficiencies (1)
Failure to complete neurological checks and fall follow-up documentation for three residents who had unwitnessed falls.
Report Facts
Facility census: 55
Falls documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Interviewed regarding responsibility for neurological checks and fall follow-up documentation |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Interviewed regarding responsibility for neurological checks and fall follow-up documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding responsibility for ensuring neurological checks are completed |
| Administrator | Administrator | Interviewed regarding expectations for neurological checks and documentation |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a failure to provide proper transfer assistance to a resident, resulting in injury.
Complaint Details
The complaint investigation found that staff did not utilize two-person assistance as required for Resident #1, leading to a leg injury. The resident was assessed as requiring two-person transfers due to severe cognitive impairment and bilateral lower extremity impairments. Staff interviews indicated confusion or lack of awareness about the resident's transfer needs.
Findings
Facility staff failed to follow the care plan requiring two-person assistance for transfers, leading to a resident sustaining a comminuted tibia-fibula fracture. Interviews revealed inconsistent knowledge and adherence to transfer protocols among staff.
Deficiencies (1)
Failure to provide proper transfer assistance as required by the resident's care plan, resulting in injury.
Report Facts
Facility census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Documented resident's leg pain and injury |
| Certified Nursing Assistant B | Certified Nursing Assistant | Interviewed regarding resident transfer knowledge |
| Certified Nursing Assistant C | Certified Nursing Assistant | Interviewed about transferring resident alone |
| Certified Nursing Assistant D | Certified Nursing Assistant | Interviewed about resident transfer requirements |
| Certified Nursing Assistant E | Certified Nursing Assistant | Interviewed about care plan alerts and transfer practices |
| Physical Therapist | Physical Therapist | Interviewed about resident transfer assessment |
| Administrator | Administrator | Interviewed about facility policy and staff adherence |
| Resident's Physician | Physician | Interviewed about resident's frailty and transfer needs |
Inspection Report
Routine
Census: 53
Deficiencies: 7
Date: Nov 17, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident dignity, care planning, medication administration, respiratory care, food safety, and infection prevention.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, incomplete and outdated care plans, failure to maintain professional standards in documentation and medication storage, inadequate respiratory equipment cleaning and storage, improper food storage and handling practices, failure to perform proper hand hygiene, and lack of a designated qualified infection preventionist.
Deficiencies (7)
Facility staff failed to ensure residents were treated with dignity and privacy, including failure to announce themselves before entering rooms and improper display of care signs visible from hallways.
Failed to update resident care plans to reflect current needs such as oxygen use and code status changes.
Failed to maintain professional standards of documentation including lack of physician orders for assistive devices, incomplete bed rail assessments, missed weekly skin assessments, and failure to consult physician on dietary recommendations.
Failed to clean and store respiratory equipment properly to prevent infection for nine residents, including dirty filters, undated tubing, and nebulizer masks not stored in bags.
Failed to store and label medications and biologicals safely and securely, including unlocked medication and treatment carts, expired and unlabeled medications, and medications left unattended.
Failed to procure, store, prepare, and serve food in accordance with professional standards, including undated and uncovered food items, failure to perform hand hygiene, use of wet stacked dishes, and failure to wear hair restraints in the kitchen.
Failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
Report Facts
Facility census: 53
Deficiency count: 7
Oxygen tubing change frequency: 1
Medication expiration date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT C | Certified Medication Technician | Interviewed regarding dignity, privacy, and oxygen tubing practices |
| LPN B | Licensed Practical Nurse | Interviewed regarding skin assessments and dietary recommendations |
| DON | Director of Nursing | Interviewed regarding care plan updates, medication storage, and infection control |
| Administrator | Interviewed regarding facility policies on dignity, medication storage, and infection control | |
| DM | Dietary Manager | Interviewed regarding food storage, hand hygiene, and hair restraint policies |
| DA M | Dietary Aide | Observed and interviewed regarding hand hygiene and food service |
| DA N | Dietary Aide | Observed handwashing practices |
| Resident #34 | Interviewed regarding dignity and privacy concerns | |
| Resident #15 | Observed during oxygen and nebulizer use |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where a Certified Nursing Assistant (CNA A) physically abused a resident by not releasing the resident's wrists during a transfer and forcefully pushing the resident in the stomach, resulting in a bruise.
Complaint Details
The complaint investigation was substantiated. CNA A physically abused Resident #1 on 7/27/23 by holding the resident's wrists and pushing the resident in the stomach. The incident was witnessed by LPN B and other staff. CNA A was suspended, investigated, and terminated. The local police and Department of Health and Senior Services were notified. The resident had a purple bruise on the right arm documented during follow-up.
Findings
The investigation found that CNA A physically abused Resident #1 by holding the resident's wrists during a transfer and then forcefully pushing the resident in the stomach with a closed fist, causing a bruise. The facility took immediate action by suspending and terminating CNA A, notifying appropriate parties, and providing staff education on abuse and neglect policies.
Deficiencies (1)
Facility staff failed to ensure one resident remained free from physical abuse when a staff member did not release the resident's wrists during a transfer and forcefully pushed the resident in the stomach, resulting in a bruise.
Report Facts
Facility census: 54
Bruise measurement: 2.5
Bruise measurement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in physical abuse finding for holding resident's wrists and pushing resident in the stomach |
| LPN B | Licensed Practical Nurse | Witnessed the abuse incident and notified the administrator |
| CNA C | Certified Nursing Assistant | Witness and reporter of the incident, assisted in lifting the resident |
| CNA D | Certified Nursing Assistant | Witness and reporter of the incident, assisted in lifting the resident |
| Administrator | Facility Administrator | Notified of the incident, removed CNA A from the building, and terminated CNA A |
| Assistant Director of Nursing | ADON | Completed investigation and suspended CNA A pending investigation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 9, 2023
Visit Reason
The document is an annual inspection report for Stonebridge Adams Street nursing home, summarizing the findings of the survey completed on 08/09/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Stonebridge Adams Street nursing home, summarizing the findings from the survey completed on 07/21/2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 53
Deficiencies: 9
Date: Jun 3, 2022
Visit Reason
Routine inspection of Stonebridge Adams Street nursing home to assess compliance with regulatory requirements including resident fund security, resident rights notification, care planning, medication management, catheter care, bed rail use, and food storage.
Findings
The facility was found deficient in multiple areas including failure to maintain adequate surety bond for resident funds, failure to inform residents of their rights, incomplete and outdated care plans for residents, inadequate documentation and physician orders for catheter care and oxygen use, failure to properly assess and monitor bed rail use, failure to follow professional standards for medication management including psychotropic drugs, and improper food storage practices.
Deficiencies (9)
Facility staff failed to maintain a surety bond sufficient to ensure protection of resident funds for all sampled residents.
Facility staff failed to inform residents of their rights during their stay in the facility.
Facility staff failed to develop and implement comprehensive person-centered care plans addressing residents' medical and nursing needs including code status, falls, and oxygen use.
Facility staff failed to revise care plans timely for changes in residents' conditions and failed to follow care plans for fall prevention.
Facility staff failed to provide care consistent with professional standards including failure to document assessments and notify physicians after resident falls, failure to obtain physician orders for code status and oxygen, and failure to clean oxygen concentrator filters.
Facility staff failed to obtain physician orders for indwelling urinary catheters, catheter care, catheter/balloon size, and indication for use for residents, including one with a urinary tract infection.
Facility staff failed to complete ongoing assessments and obtain consents for bed rail use to assure they met residents' needs.
Facility staff failed to ensure appropriate indications and diagnoses for psychotropic medication use, failed to attempt gradual dose reductions, and failed to communicate pharmacy recommendations to physicians.
Facility staff failed to store food properly to prevent cross-contamination and out-dated use, including unlabeled, undated, unsealed, and spoiled food items in refrigerators and freezers.
Report Facts
Facility census: 53
Residents sampled for surety bond: 18
Average monthly balance: 29324
Required bond amount: 43986
Current bond amount: 30000
Psychotropic medication days: 7
Food storage violation count: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Named in surety bond deficiency interviews | |
| Administrator | Named in surety bond, resident rights, care plan, oxygen, catheter care, bed rail, and food storage deficiencies | |
| Certified Nurse Aide F | CNA | Interviewed regarding resident rights, care plans, oxygen, catheter care, bed rail assessments |
| Certified Nurse Aide G | CNA | Interviewed regarding resident rights, care plans, catheter care, bed rail assessments |
| Director of Nursing | DON | Interviewed regarding care plans, oxygen, catheter care, bed rail assessments, medication management |
| Assistant Director of Nursing | ADON | Interviewed regarding resident rights, care plans, catheter care, oxygen |
| Social Services Director | SSD | Interviewed regarding resident rights, care plans, catheter care, code status |
| MDS Coordinator | Interviewed regarding resident rights, care plans, catheter care, medication management | |
| Registered Nurse D | RN | Interviewed regarding care plans, falls, catheter care, bed rail use |
| Licensed Practical Nurse E | LPN | Interviewed regarding oxygen filter cleaning |
| Dietary Manager | DM | Interviewed regarding food storage and labeling |
| Regional Nurse Consultant | Interviewed regarding medication management | |
| Physician A | Physician | Interviewed regarding catheter care and medication management |
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