Inspection Reports for
Stonebridge Florissant
6768 NORTH HIGHWAY 67, FLORISSANT, MO, 63034-2742
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
133% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
55% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Date: Aug 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to document physician orders verification and medication administration for Resident #74 admitted for respite care.
Complaint Details
The complaint involved failure to verify and document physician orders and failure to administer medications as ordered for Resident #74. The resident was admitted for respite care and had multiple diagnoses. The facility did not have a discharge summary or after care summary. Medication orders were inconsistently documented and verified. The resident experienced behavioral issues and falls during the stay. The facility failed to notify the physician of missed medications and did not properly document fingerstick blood sugar results or insulin administration.
Findings
The facility failed to verify and document physician orders for Resident #74 upon admission and failed to provide necessary medications as ordered. Additionally, the facility did not notify or document notification to the physician regarding missed medications. There were issues with medication reconciliation, documentation of fingerstick blood sugars, and insulin administration. The resident experienced behavioral issues and falls during the stay.
Deficiencies (2)
Failed to document physician orders were verified for Resident #74 admitted for respite care.
Failed to provide necessary medications as ordered and failed to notify and document physician notification of missed medications for Resident #74.
Report Facts
Census: 66
Sample size: 17
Medication administration record dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON A | Assistant Director of Nursing | Interviewed regarding admission process and medication order verification failures |
| RN D | Registered Nurse | Responsible for admission assessments and entering medication orders; involved in medication order transcription errors |
| ADON B | Assistant Director of Nursing | Interviewed regarding admission process, failure to obtain resident's admission information, and medication administration issues |
| LPN C | Licensed Practical Nurse | Interviewed about medication administration and fingerstick blood sugar documentation |
| CMT E | Certified Medication Technician | Interviewed about medication administration and documentation |
| CMT F | Certified Medication Technician | Interviewed about medication administration and documentation |
| DON | Director of Nursing | Interviewed about expectations for medication administration and physician notification |
| Regional Nurse | Regional Nurse | Interviewed about resident documentation and medication administration |
| Physician | Interviewed about verification of physician orders and notification of missed medications | |
| Administrator | Interviewed about admission process and medication order verification |
Inspection Report
Routine
Census: 66
Deficiencies: 8
Date: Aug 22, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident fund management, communication access, bed-hold policy notification, physician orders verification, neurological checks after falls, wound care, RN staffing, and medication administration.
Findings
The facility was found deficient in multiple areas including failure to complete third party liability forms timely, lack of mail delivery on Saturdays, failure to provide bed-hold notices upon hospital transfer, incomplete verification of physician orders on admission, failure to perform neurological checks after an unwitnessed fall, inadequate wound care documentation and treatment transcription, insufficient RN coverage, and medication administration errors including missed doses and lack of physician notification.
Deficiencies (8)
Failed to ensure third party liability forms were completed within 30 days for residents who expired with money in their accounts.
Failed to ensure residents had access to mail delivered on Saturdays.
Failed to provide written notice of bed-hold policy to residents or representatives upon hospital transfer.
Failed to document physician orders were verified for one resident admitted for respite care.
Failed to perform neurological checks after an unwitnessed fall for one resident.
Failed to provide appropriate pressure ulcer care and prevent new ulcers by not documenting thorough wound assessments weekly and not transcribing hospital wound treatment orders.
Failed to have a registered nurse on duty at least 8 consecutive hours a day, 7 days a week.
Failed to provide necessary medications as ordered, failed to notify and document physician notification of missed medications for one resident.
Report Facts
Sample size: 17
Census: 66
Medication doses held: 7
RN hours missing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Responsible for admission assessments and entering physician orders; involved in medication transcription error |
| ADON A | Assistant Director of Nursing | Interviewed regarding admission process, neurological checks, wound care, and medication administration |
| ADON B | Assistant Director of Nursing | Interviewed regarding admission process, wound care, and medication administration |
| LPN C | Licensed Practical Nurse | Interviewed regarding neurological checks and medication administration |
| CMT F | Certified Medication Technician | Interviewed regarding medication administration and documentation |
| DON | Director of Nursing | Interviewed regarding neurological checks, wound care, and medication administration expectations |
| Administrator | Interviewed regarding mail delivery, bed-hold notices, RN staffing, and medication administration expectations | |
| Business Office Manager | Interviewed regarding late submission of third party liability notifications | |
| Activity Director | Interviewed regarding mail delivery on Saturdays | |
| Regional Nurse | Interviewed regarding admission documentation and neurological checks |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Date: Apr 21, 2025
Visit Reason
The inspection was conducted due to a complaint regarding a resident (Resident #7) who fell out of bed when left unattended by a Certified Nurse Assistant (CNA), resulting in a head injury and failure to immediately assess and notify appropriate parties.
Complaint Details
The complaint involved Resident #7 falling out of bed while being cared for by a CNA who left the resident unattended. The fall resulted in a head injury. The CNA failed to immediately report the fall to the charge nurse. The facility investigated and found the CNA was newly hired and unaware of the requirement to care in pairs. Education was provided and the incident was addressed as a teachable moment.
Findings
The facility failed to keep residents free from accidents and injuries by leaving a resident unattended, causing a fall. The resident was not immediately assessed or reported to the Primary Care Physician, responsible party, or interdisciplinary team. The facility responded with appropriate assessment, hospital transfer, and staff education after the incident.
Deficiencies (2)
Failure to keep residents free from accidents and injuries when a resident fell out of bed due to being left unattended by a CNA.
Failure to ensure residents were assessed immediately after a fall for injury and failure to notify the PCP, responsible party, and interdisciplinary team after the fall.
Report Facts
Census: 70
Date of fall incident: Jan 17, 2025
Date of staff education: Jan 17, 2025
Date of deficiency correction: Jan 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Assistant | Named in the fall incident for leaving resident unattended and failing to immediately report the fall |
| LPN A | Licensed Practical Nurse | Assessed resident after fall, notified Director of Nursing and PCP, and provided information on incident |
| LPN C | Licensed Practical Nurse | Night shift nurse who received report of fall from CNA B |
| ADON | Assistant Director of Nursing | Addressed CNA B with a teachable moment and provided education on fall policy |
| Administrator | Informed of the resident's fall and participated in investigation and review of policies | |
| DON | Director of Nursing | Informed of the resident's fall and participated in investigation and review of policies |
Inspection Report
Routine
Census: 82
Deficiencies: 10
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding fall prevention and post-fall assessments following a resident fall incident.
Findings
The facility failed to implement timely and appropriate interventions to prevent falls and adequately assess and document post-fall care for multiple residents, including failure to complete required neurological checks, post-fall assessments, incident follow-up documentation, and notification to physicians and resident representatives. The facility also failed to provide adequate fall mats on both sides of a resident's bed, contributing to injury.
Deficiencies (10)
Failure to implement timely and appropriate interventions to prevent falls and injury for one resident who fell from the side of the bed without a fall mat.
Failure to complete post-fall 72 hour monitoring reports including neurological checks for three residents.
Failure to complete post-fall initial clinical assessments for four residents.
Failure to complete skin assessments for two residents post-fall.
Failure to complete incident follow-up documentation for 72 hours post-fall in progress notes for five residents.
Failure to document notification to physician for one resident post-fall.
Failure to document notification of resident representative for two residents post-fall.
Failure to update residents' care plans with fall interventions for two residents.
Failure to update the nursing worksheet (kardex) binder with fall interventions for four residents.
Resident fell from the right side of the bed where no fall mat was present, resulting in injury.
Report Facts
Census: 82
Fall bruise size: 2
Fall bruise size: 2
Date of fall: Sep 13, 2024
Date of survey: Sep 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Worked the night the resident fell, described fall circumstances and post-fall procedures |
| LPN C | Licensed Practical Nurse | Relieved night nurse, described fall risk assessment and post-fall procedures |
| CNA A | Certified Nursing Assistant | Provided information about fall mats and resident care post-fall |
| CNA B | Certified Nursing Assistant | Described fall risk knowledge and fall mat placement responsibilities |
| DON | Director of Nursing | Provided information about fall mat interventions and fall incident follow-up |
| MD | Maintenance Director | Responsible for placing fall mats in resident rooms |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 4
Date: Feb 28, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to uphold residents' rights, inadequate assistance with activities of daily living (ADLs), failure to provide a safe and homelike environment, and insufficient staffing to meet residents' needs.
Complaint Details
The investigation was complaint-driven, focusing on allegations that call lights were not answered timely, residents were left in soiled briefs, showers were not provided as scheduled, dentures were not properly cleaned, and staffing was inadequate to meet resident needs. The complaints were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to uphold residents' rights by not responding timely to call lights and treating residents with dignity. Residents requiring assistance with ADLs were not provided timely or adequate care, including failure to provide showers and proper denture care. The environment was compromised by persistent urine odors due to improper handling of soiled utility bins. Staffing was insufficient to meet residents' needs, resulting in delayed responses to call lights and unmet care requirements.
Deficiencies (4)
Failure to uphold resident rights by turning off call light without assistance and inappropriate staff interaction with resident requiring clothing assistance.
Failure to provide a safe, clean, comfortable and homelike environment due to persistent strong urine odors in common areas.
Failure to provide timely personal hygiene assistance including leaving a resident in a soiled brief for an extended time, failure to provide showers to residents, and improper denture care.
Failure to provide sufficient nursing staff to meet residents' needs, resulting in delayed response to call lights and unmet care needs.
Report Facts
Sample size: 24
Census: 85
Residents needing assistance with bathing: 67
Residents dependent on bathing: 13
Residents needing assistance with dressing: 57
Residents dependent on dressing: 14
Residents needing assistance with transferring: 50
Residents dependent on transferring: 9
Residents needing assistance with toilet use: 41
Residents dependent on toilet use: 19
Residents needing assistance with eating: 46
Residents dependent on eating: 5
Staffing - Night shift East wing: 3
Staffing - Night shift [NAME] wing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Interviewed regarding staffing and failure to respond timely to call lights and resident needs | |
| Certified Medication Technician Q | Named in failure to timely assist Resident #46 and improper prioritization of care | |
| Admissions Director (AD) | Admissions Director | Turned off Resident #46's call light without ensuring assistance was provided |
| Nurse A | Observed arriving late and not immediately responding to call lights | |
| Certified Nurse Aide C | Certified Nurse Aide | Interviewed about shower provision and denture care |
| Nurse B | Interviewed about inappropriate staff behavior towards Resident #40 | |
| CNA S | Certified Nursing Assistant | Interviewed about staffing shortages and workload |
| Nurse T | Agency Nurse | Interviewed but unable to answer resident-specific questions |
| Administrator | Administrator | Interviewed about expectations for call light response, staffing, and resident dignity |
Inspection Report
Routine
Census: 85
Deficiencies: 14
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care planning, infection control, staffing, and safety.
Findings
The facility was found deficient in multiple areas including failure to uphold resident rights, inadequate care and assistance with activities of daily living, failure to maintain a safe and homelike environment, incomplete care plans, improper use of mechanical lifts, failure to maintain proper medication storage and labeling, inadequate staffing levels, failure to properly document physician orders, failure to inform residents about arbitration agreements, lack of a water management program, and failure to regularly inspect bed frames and rails.
Deficiencies (14)
Failure to uphold resident rights including dignity and timely assistance with call lights.
Failure to provide a safe, clean, comfortable, and homelike environment due to persistent urine odors in hallways.
Failure to develop and implement complete and accurate individualized care plans for residents.
Failure to provide timely personal hygiene assistance and showers, and improper denture care.
Failure to provide safe mechanical lift transfers causing resident discomfort and pain.
Failure to maintain proper positioning and care during tube feeding, increasing risk of aspiration.
Failure to provide sufficient nursing staff to meet resident needs and timely respond to call lights.
Failure to provide 8 hours of registered nurse coverage on multiple days.
Failure to limit PRN psychotropic medication orders to 14 days or less.
Failure to ensure drugs and biologicals were properly labeled, dated, and stored; medication carts and treatment carts were unclean.
Failure to maintain complete and accurate medical records including transcription errors in medication orders.
Failure to explicitly inform residents or representatives of their right not to sign arbitration agreements as a condition of admission or continued care.
Failure to develop and implement a water management program to reduce risk of Legionella and other pathogens.
Failure to regularly inspect bed frames, mattresses, and bed rails to identify entrapment risks.
Report Facts
Sample size: 24
Census: 85
Days without RN coverage: 18
Medication carts checked: 4
Medication rooms checked: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Involved in resident care and interview regarding call light response and tube feeding |
| Nurse D | Nurse | Interviewed about staffing and call light response |
| Certified Medication Technician Q | CMT | Involved in resident care and call light response |
| Admissions Director | Administrator | Interviewed about call light response, arbitration agreements, and staffing |
| Nurse B | Nurse | Interviewed about care plans, medication storage, and tube feeding |
| Certified Nurse Aide C | CNA | Interviewed about resident care and shower assistance |
| Administrator | Administrator | Interviewed about staffing, arbitration agreements, and water management |
| Maintenance Director | Maintenance Director | Interviewed about bed rail installation and maintenance |
| Regional Nurse | Nurse | Interviewed about tube feeding and mechanical lift use |
| Director of Rehabilitation | DOR | Provided therapy recommendations for resident transfers |
| Nurse K | Nurse | Interviewed about medication storage and labeling |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 1
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with standards of care related to catheter use and care, specifically addressing concerns about catheter care and documentation for a resident admitted with a Foley catheter.
Findings
The facility failed to ensure proper catheter care and documentation for Resident #1, who was admitted with a Foley catheter. The resident experienced a change in condition and was hospitalized with purulent and foul-smelling urine due to inadequate catheter care and lack of documentation of catheter output.
Deficiencies (1)
Failure to provide appropriate catheter care and document catheter output for a resident with a Foley catheter, leading to infection and hospitalization.
Report Facts
Census: 85
Catheter drainage volume: 340
Catheter drainage volume: 400
Purulent drainage volume: 1300
Purulent drainage volume: 100
Purulent drainage volume: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed regarding catheter care procedures and documentation | |
| Director of Nursing | Interviewed regarding missing catheter output documentation | |
| Administrator | Interviewed regarding missing catheter output documentation and resident condition |
Inspection Report
Routine
Census: 81
Deficiencies: 10
Date: May 25, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, emergency response, resident rights, care planning, quality of care, infection control, and other aspects of resident care.
Findings
The facility was found deficient in multiple areas including failure to ensure safe self-administration of medications, inconsistent emergency response to code status, failure to notify family of significant changes, incomplete and inaccurate care plans, failure to follow physician orders, inadequate monitoring of residents with change in condition, lack of restorative therapy services, medication administration errors, incomplete documentation, and poor infection control practices during personal care.
Deficiencies (10)
Failed to ensure residents could safely self-administer medications as clinically appropriate.
Failed to ensure correct emergency response for a resident with conflicting code statuses (DNR and full code).
Failed to notify resident's representative regarding significant change in condition requiring suicide watch.
Failed to respect residents' right to privacy during personal care, including improper use of privacy curtains and exposure to others.
Failed to develop and implement complete, accurate, and individualized care plans addressing wounds, transfers, ADLs, incontinence, colostomy care, code status, oxygen use, weight loss, hospice services, and falls.
Failed to ensure care and services met professional standards, including failure to follow treatment orders, diet orders, physician follow-up, and accurate assessment of dialysis access site.
Failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility; facility lacked restorative therapy policies and program.
Medication error rate exceeded 5%, including failure to document administration and improper medication preparation and administration via gastrostomy tube.
Failed to maintain complete and accurate medical records, including documentation of medication administration, pain assessments, and monitoring of residents' conditions.
Failed to follow infection control practices during personal care, including improper glove use, hand hygiene, and handling of soiled washcloths.
Report Facts
Medication error rate: 13.79
Residents with contractures: 23
Medication administration documentation failures: 9
Medication administration documentation failures: 9
Medication administration documentation failures: 8
Medication administration documentation failures: 5
PRN Percocet administrations: 84
PRN Percocet documentation failures: 76
Medication administration documentation failures: 4
Medication administration documentation failures: 4
Medication administration documentation failures: 5
Medication administration documentation failures: 1
PRN Percocet administrations: 60
PRN Percocet documentation failures: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse O | Nurse | Mentioned in relation to medication administration and self-administration findings. |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding care plan expectations, medication administration, infection control, and other findings. |
| Nurse Practitioner T | Nurse Practitioner | Provided interview regarding expectations for monitoring residents with change in condition. |
| Licensed Practical Nurse H | Licensed Practical Nurse (LPN) | Observed administering medications via gastrostomy tube with errors. |
| Certified Nursing Assistant C | Certified Nursing Assistant (CNA) | Observed providing personal care with infection control deficiencies. |
| Certified Nursing Assistant I | Certified Nursing Assistant (CNA) | Observed providing personal care with infection control deficiencies. |
| Physical Therapist F | Physical Therapist (PT) | Provided interview regarding restorative therapy program suspension. |
| Occupational Therapist K | Occupational Therapist (OT) | Provided interview regarding resident care and therapy instructions. |
| Licensed Practical Nurse R | Licensed Practical Nurse (LPN) | Interviewed about discharge summary documentation. |
| Licensed Practical Nurse S | Licensed Practical Nurse (LPN) | Interviewed about change in condition nursing responsibilities. |
| Dietary Aide P | Dietary Aide | Interviewed about dietary orders and meal preparation. |
| Nurse H | Nurse | Interviewed about wound care orders and treatment. |
| Social Worker | Social Worker (SW) | Interviewed about suicide watch and resident behavior support. |
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