Inspection Reports for
Stonebridge Florissant
6768 NORTH HIGHWAY 67, FLORISSANT, MO, 63034-2742
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
173% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
36
27
18
9
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
Plan of Correction
Census: 82
Deficiencies: 2
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to investigate and document deficiencies related to resident falls and accident hazards at Stonebridge Florissant nursing facility.
Findings
The facility failed to implement timely and appropriate interventions to prevent falls and adequately assess residents after falls. Documentation and care planning related to fall risk and post-fall assessments were incomplete or missing for multiple residents.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to prevent falls and adequately assess residents after falls, resulting in injury to one resident and incomplete post-fall monitoring for others.
A4075 Nursing Care per Resident Condition: Each resident did not receive personal attention and nursing care consistent with current acceptable nursing practices, as evidenced by deficiencies cited at F689.
Report Facts
Census: 82
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
Life Safety
Census: 85
Capacity: 109
Deficiencies: 5
Date: Mar 5, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Survey were conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri to assess compliance with Medicare/Medicaid requirements and the Life Safety Code.
Findings
The facility was found to be in compliance with emergency preparedness regulations but was found to be in noncompliance with Life Safety Code requirements related to hazardous area enclosures, sprinkler system maintenance, corridor door closures, electrical systems, and gas equipment training. Deficiencies had the potential to affect residents and staff.
Deficiencies (5)
K321 Hazardous Areas - Enclosure: The facility failed to separate hazardous areas from other parts of the facility as required by NFPA 101. The kitchen door did not properly close, potentially affecting all 85 residents.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system per NFPA 25 standards. Missing weekly inspection reports and excess corrosion on sprinkler heads were observed, potentially affecting all 85 residents.
K363 Corridor - Doors: Corridor doors failed to close and latch properly, including a door blocked by a trash can. This deficient practice had the potential to affect 22 residents.
K918 Electrical Systems - Essential Electric System: The facility failed to meet NFPA 110 requirements for emergency power system maintenance and testing. Missing weekly generator inspection records and lack of a remote manual stop station were noted, potentially affecting all 85 residents and staff.
K926 Gas Equipment - Qualifications and Training: The facility failed to ensure personnel were trained in the safe handling of medical gases and cylinders as required by NFPA 99, potentially affecting all 85 residents.
Report Facts
Residents affected: 85
Residents affected: 22
Total licensed beds: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Cooper | Administrator | Named in relation to findings and plan of correction |
| Maintenance Director | Interviewed regarding door and sprinkler system deficiencies | |
| Sprinkler Technician | Interviewed regarding sprinkler system deficiencies | |
| Fire Alarm Monitoring Company representative | Interviewed regarding fire alarm supervisory signal |
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
Plan of Correction
Census: 85
Deficiencies: 2
Date: Nov 3, 2023
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident care, specifically focusing on catheter care and continence management.
Findings
The facility failed to ensure proper catheter care for a resident with a Foley catheter, resulting in inadequate documentation of catheter output and subsequent infection. The resident experienced a serious urinary tract infection requiring hospitalization.
Deficiencies (2)
F690: The facility did not ensure a resident with a Foley catheter received catheter care per standards, failing to document catheter output. This led to a urinary tract infection and hospitalization.
A4075: The facility failed to provide personal nursing care consistent with resident condition, as evidenced by the deficiency cited at F690.
Report Facts
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Cooper | WNA | Signed the statement of deficiencies and plan of correction |
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
Plan of Correction
Census: 80
Deficiencies: 2
Date: Jul 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to pressure ulcer prevention and treatment at Stonebridge Florissant.
Findings
The facility failed to provide adequate interventions, monitoring, and care for residents at risk of or with pressure ulcers, resulting in the development and deterioration of Stage III and IV pressure ulcers. Documentation and treatment administration were inconsistent and incomplete.
Deficiencies (2)
F686: The facility failed to prevent and properly treat pressure ulcers, including failure to provide ordered treatments and weekly skin assessments, resulting in worsening pressure ulcers for residents.
A4083: Facilities shall keep residents free from avoidable pressure sores and provide adequate treatment if sores exist. This regulation was not met as evidenced by the deficiency cited at F686.
Report Facts
Census: 80
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Nurse C | Mentioned in relation to wound care treatments and weekly skin assessments | |
| Director of Nursing | Mentioned regarding knowledge of wound treatments and staff education | |
| Wound Nurse B | Mentioned in relation to wound treatments and observations | |
| Wound Nurse A | Mentioned regarding responsibility to assess and describe wounds |
Inspection Report
Life Safety
Census: 85
Deficiencies: 2
Date: May 26, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code requirements, specifically regarding patient-care related electrical equipment and electrical system certification.
Findings
The facility failed to have policies and protocols for testing patient-care related electrical equipment and did not have an electrical inspection completed every two years as required. These deficiencies had the potential to affect all building occupants.
Deficiencies (2)
19 CSR 30-85.012(79) LSC Edition Required per Date of Fac Plan: The facility failed to have policies and protocols for testing patient-care related electrical equipment based on manufacturer's instructions and procedures. The census was 85.
19 CSR 30-85.032(31)(B) Electrical System-Certification Every 2 Years: The facility failed to have an electrical inspection completed every two years as required. The census was 85.
Report Facts
Census: 85
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 7, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 01/05/2022 through 01/07/2022 to assess compliance with relevant CMS and CDC requirements.
Complaint Details
This was a complaint investigation related to COVID-19 infection control. No deficiencies were cited as a result of the investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Plan of Correction
Census: 89
Deficiencies: 4
Date: Nov 8, 2021
Visit Reason
The inspection was conducted to assess compliance with medication administration and narcotic count policies, following identified deficiencies related to medication errors and labeling.
Findings
The facility failed to ensure residents were free of significant medication errors, specifically in administering narcotic pain medication and monitoring narcotic counts. Deficiencies were found in medication administration timing, narcotic count discrepancies, and labeling and storage of drugs and biologicals.
Deficiencies (4)
F760 Residents are not free of significant medication errors as the facility failed to administer narcotic pain medication according to physician orders, with multiple instances of medication given too close together. The facility's medication administration records showed discrepancies in timing and documentation.
F761 The facility failed to monitor narcotic count sheets accurately for one resident, missing discrepancies and not investigating or resolving them properly. The medication storage policy was not fully followed, leading to unaccounted narcotic doses.
A4059 All medication errors and adverse reactions were not reported immediately to the nursing supervisor, resident's physician, and issuing pharmacist as required by regulation.
A4061 Prescription medications were not labeled in accordance with professional pharmacy standards and federal laws, lacking proper accessory and cautionary instructions and expiration dates.
Report Facts
Sample size: 6
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Interviewed regarding medication administration procedures | |
| Administrator | Interviewed regarding narcotic audits and medication errors | |
| Director of Nursing | DON | Provided information on medication administration and narcotic count procedures |
Inspection Report
Life Safety
Census: 81
Capacity: 120
Deficiencies: 6
Date: May 25, 2021
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety and building construction standards, including smoke resistance, fire resistance, signage, egress requirements, and sprinkler system maintenance.
Findings
The facility failed to meet several Life Safety Code requirements including maintaining proper fire-resistant construction, appropriate signage on delayed egress doors, and sprinkler system maintenance. Deficiencies were found in smoke compartment integrity, signage visibility, sprinkler head condition, and electrical receptacle testing.
Deficiencies (6)
K161: The facility failed to maintain appropriate construction standards with proper smoke resisting and fire resistance rated ceilings to protect the attic. Holes in ceilings allowed passage of smoke and fire.
K200: The facility failed to maintain proper signage on doors leading to enclosed courtyard areas, with signs not readily visible or meeting code requirements.
K222: The facility failed to maintain proper signage on seven delayed egress doors, lacking contrasting backgrounds for visibility.
K324: The facility failed to maintain the kitchen range hood in accordance with NFPA standards, including grease buildup and a broken manual actuator.
K353: The facility failed to maintain the sprinkler system per NFPA 25, with sprinkler heads corroded, dusty, or obstructed in multiple locations.
K914: The facility failed to ensure annual testing and documentation of non-hospital grade electrical receptacles in resident sleeping areas was properly completed and recorded.
Report Facts
Facility capacity: 120
Resident census: 81
Deficiency counts: 6
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. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 11/14/2020 through 11/17/2020 to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
The complaint investigation found no deficiencies and the facility was compliant with infection control requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 10/19/2020 through 10/20/2020 to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 08/11/2020 through 08/13/2020 to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 07/22/2020 through 07/24/2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 06/18/2020 through 06/23/2020 to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
Date: Aug 19, 2019
Visit Reason
The inspection was conducted as a complaint survey to investigate medication administration practices at The Valley a Stonebridge Community.
Complaint Details
The visit was complaint-related, focusing on medication administration issues. The complaint was substantiated as the facility failed to administer medications timely and document properly.
Findings
The facility failed to administer physician-prescribed medications as ordered and per facility policy for residents receiving morning medications. Multiple observations and interviews revealed late medication administration and incomplete documentation.
Deficiencies (2)
F684 Quality of care: The facility failed to ensure residents received medications within the prescribed time frame and did not properly document medication administration. This included late administration and missing documentation for multiple residents.
A4054 Safe/Effective Medication System: The facility did not maintain a safe and effective system of medication distribution, administration, control, and use, as evidenced by the deficiency cited at F684.
Report Facts
Resident census: 97
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Supervisor | Mentioned in relation to administering medications late and assisting with medication administration | |
| Certified Medication Technician K | Certified Medication Technician | Observed passing morning medications and interviewed about medication administration timing |
| Certified Medication Technician J | Certified Medication Technician | Observed passing medications and interviewed about medication administration timing and documentation |
| Nurse F | Interviewed regarding medication administration and documentation | |
| Director of Nursing | DON | Interviewed about medication administration policies and corrective actions |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 2
Date: Jul 10, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to resident safety and supervision, specifically concerning the use of mechanical lifts and prevention of accidents.
Complaint Details
The complaint investigation was substantiated, focusing on a resident fall from a mechanical sit to stand lift due to staff not following policy and inadequate supervision and reporting.
Findings
The facility failed to ensure staff followed proper mechanical lift policies, resulting in a resident falling from a sit to stand lift. Documentation and reporting of the incident were inadequate, and staff were not properly trained or supervised in the use of mechanical lifts.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure staff safely operated sit to stand mechanical lifts, resulting in a resident falling from the lift and inadequate reporting of the incident.
A4073 Protective Oversight, Voluntary Leave: The facility did not provide adequate 24-hour protective oversight and supervision for residents on voluntary leave, as referenced in deficiency F689.
Report Facts
Census: 99
Date of Survey: Jul 10, 2019
Completion Date: Aug 6, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse F | Named in resident fall incident and interview regarding mechanical lift use | |
| CNA A | Certified Nurse Aide | Involved in resident transfer and incident reporting |
| CNA B | Certified Nurse Aide | Involved in resident transfer and incident reporting |
| CNA C | Certified Nurse Aide | Observed mechanical lift issues and assisted resident transfers |
| CNA D | Certified Nurse Aide | Observed mechanical lift issues and assisted resident transfers |
| Nurse G | Interviewed regarding staff use of mechanical lifts | |
| Director of Nursing | Director of Nursing (DON) | Interviewed about mechanical lift policies and staff training |
| Administrator | Administrator | Interviewed about mechanical lift policies and manufacturer guidelines |
Inspection Report
Annual Inspection
Census: 97
Deficiencies: 13
Date: Mar 5, 2019
Visit Reason
The inspection was the annual survey of The Valley a Stonebridge Community to assess compliance with federal and state regulations for nursing facilities.
Findings
The facility was found to have multiple deficiencies related to resident self-determination, abuse prevention, accuracy of assessments, comprehensive person-centered care plans, accident prevention, bowel/bladder incontinence management, respiratory care, pharmacy services, food safety, and staff training. Plans of correction were submitted to address these issues.
Deficiencies (13)
F 561 Self-determination: The facility failed to promote resident self-determination and support resident choices, including meal preferences and social activities.
F 600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to ensure a resident was free from verbal abuse by staff and did not properly investigate and respond to the incident.
F 641 Accuracy of Assessments: The facility failed to accurately assess residents' mental status and document diagnoses and medications.
F 655 Baseline Care Plans: The facility failed to develop and implement baseline care plans within 48 hours of admission for residents.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure residents were free from accident hazards related to smoking and catheter care.
F 690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure proper assessment, care, and documentation for residents with indwelling urinary catheters.
F 693 Tube Feeding/Mgmt/Restore Eating Skills: The facility failed to ensure residents with feeding tubes had accurate care plans and proper feeding documentation.
F 695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to provide adequate oxygen therapy and respiratory care for residents.
F 698 Dialysis: The facility failed to ensure residents receiving dialysis had comprehensive care plans and documentation.
F 730 In-service Training-Nursing Personnel: The facility failed to provide required in-service training hours for certified nursing assistants.
F 755 Pharmacy Services: The facility failed to maintain accurate records of controlled substances and ensure proper drug regimen reviews.
F 804 Food and Drink: The facility failed to maintain proper food temperatures and safe food storage.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to store, prepare, and serve food in accordance with professional standards of food service safety.
Report Facts
Census: 97
Deficiencies cited: 12
Inspection Report
Life Safety
Census: 97
Deficiencies: 4
Date: Mar 5, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code and related NFPA regulations, focusing on fire safety and hazardous areas.
Findings
The facility failed to maintain exit corridor doors free from impediments, maintain kitchen range hood inspections, maintain smoking areas, and properly store oxygen tanks. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (4)
K321 Hazardous areas are not protected by required fire barriers or automatic fire extinguishing systems, and exit corridor doors were impeded from closing by a wedged fork.
K324 The facility failed to maintain the kitchen range hood and wet chemical suppression system with required monthly inspections.
K741 Smoking regulations were not met as cigarette butts were found near exit egress doors and smoking areas were not properly maintained.
K923 Oxygen storage was not maintained according to NFPA code; oxygen tanks were not stored in racks and were improperly placed.
Report Facts
Facility census: 97
Cigarette butts count: 60
Cigarette butts count: 25
Date of inspection: Mar 5, 2019
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 21
Date: Mar 2, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for the Valley-A Stonebridge Community nursing facility.
Findings
The survey identified multiple deficiencies related to resident rights, medication administration, quality of care, safety, and documentation. The facility failed to meet several regulatory requirements including resident privacy, medication management, pressure ulcer prevention, and abuse prevention.
Deficiencies (21)
F550 Resident Rights: The facility failed to ensure residents' rights to dignity, privacy, and exercise of rights were respected and protected.
F554 Self-Administered Medications: The facility failed to ensure residents could self-administer medications safely and appropriately.
F580 Notification of Changes: The facility failed to notify the resident, physician, and representative of significant changes in condition.
F583 Privacy and Confidentiality: The facility failed to protect residents' privacy and confidentiality during care and in personal records.
F584 Safe/Comfortable/Homelike Environment: The facility failed to maintain a safe, clean, and homelike environment, including housekeeping and maintenance.
F608 Reporting of Crimes: The facility failed to report alleged crimes and abuse to appropriate authorities timely.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide proper notice before resident transfer or discharge.
F656 Comprehensive Care Plan: The facility failed to develop and implement comprehensive care plans addressing residents' needs.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide timely and adequate personal care to dependent residents.
F684 Quality of Care: The facility failed to provide care and treatment to prevent pressure ulcers and manage wounds effectively.
F689 Abuse: The facility failed to prevent and properly investigate resident abuse and neglect.
F693 Feeding Management/Restore Eating Skills: The facility failed to ensure residents received adequate nutrition and feeding assistance.
F730 Nurse Aide Training: The facility failed to ensure certified nurse aides received required annual training.
F742 Provision of Medically Related Social Services: The facility failed to provide adequate social services to residents.
F745 Nutritional Status: The facility failed to provide adequate nutrition and hydration to residents.
F759 Medication Errors: The facility failed to maintain medication error rates below 5%.
F761 Labeling of Drugs and Biologicals: The facility failed to properly label and store medications and biologicals.
F803 Menus and Nutritional Adequacy: The facility failed to provide menus that meet residents' nutritional needs.
F842 Resident Records: The facility failed to maintain complete, accurate, and accessible medical records.
F849 Hospice Services: The facility failed to provide appropriate hospice care and coordination for residents.
F850 Furniture/Equipment, Protection & Safety: The facility failed to maintain furniture and equipment in safe condition.
Report Facts
Resident census: 77
Deficiency count: 21
Inspection Report
Life Safety
Census: 77
Capacity: 120
Deficiencies: 4
Date: Mar 2, 2018
Visit Reason
The inspection was conducted to evaluate compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility was found deficient in maintaining the sprinkler system and smoke barriers according to fire safety standards. The sprinkler system was out of service and the smoke barriers did not meet the required fire resistance rating, with unsealed penetrations noted.
Deficiencies (4)
K354 Sprinkler System - Out of Service. The facility failed to develop an adequate fire watch policy for staff to follow when the sprinkler system was out of service. The facility has a capacity of 120 and had a census of 77 residents at the time of the survey.
K372 Subdivision of Building Spaces - Smoke Barrier. The facility failed to ensure smoke barriers were maintained to provide the required 1/2-hour fire resistance rating. Unsealed gaps were observed in smoke barrier walls near rooms 212, 225, and 114.
A2036 Sprinkler System Out of Service More Than 4hr. The facility did not immediately notify the department and local fire authority or implement an approved fire watch when the sprinkler system was out of service for more than four hours.
A2054 Smoke Section Walls/Doors. The facility failed to maintain smoke section walls and doors to meet fire rating requirements and automatic door closing upon fire alarm activation.
Report Facts
Facility capacity: 120
Resident census: 77
Deficiency count: 4
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