Deficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
68 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 2
Date: Jul 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning and infection prevention and control at Stonebridge Villa Marie nursing home.
Findings
The facility failed to properly review and revise care plans for three residents, missing documentation of behavior interventions and activity preferences. Additionally, infection control procedures were not properly followed, including failure to perform hand hygiene between glove changes and improper disposal of contaminated linens, as well as inadequate implementation of enhanced barrier precautions.
Deficiencies (2)
Failed to develop and revise comprehensive care plans within 7 days of assessment for three residents, lacking interventions for behaviors and activity preferences.
Failed to provide and implement an infection prevention and control program, including failure to perform hand hygiene between glove changes, improper disposal of contaminated linens, and inadequate use of enhanced barrier precautions.
Report Facts
Facility census: 68
Residents affected: 3
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT D | Certified Medication Technician | Named in infection control deficiency for failure to perform hand hygiene and use enhanced barrier precautions |
| CNA E | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene and use enhanced barrier precautions |
| CNA F | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene and glove changes |
| LPN A | Licensed Practical Nurse | Named in infection control deficiency for failure to wear gown during wound care |
| LPN B | Licensed Practical Nurse | Named in infection control deficiency related to contaminated linens |
| CNA J | Certified Nursing Assistant | Named in infection control deficiency related to contaminated linens |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding care plan and infection control deficiencies and responsibilities |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan and infection control deficiencies and responsibilities |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan deficiencies and updating process |
| Administrator | Administrator | Interviewed regarding care plan purpose and updating process |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: Jan 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of sexual assault involving one resident at the facility.
Complaint Details
The complaint involved an allegation of sexual assault by Resident #1. The allegation was not thoroughly investigated, and the facility failed to report the allegation to DHSS within two hours and did not notify local law enforcement. The allegation was ultimately not substantiated according to the facility's internal investigation.
Findings
The facility failed to thoroughly investigate the allegation of sexual assault, did not obtain signed and dated statements from staff or witnesses, and failed to interview other residents. Additionally, the facility did not report the allegation to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe and failed to notify local law enforcement.
Deficiencies (2)
Failed to thoroughly investigate an allegation of sexual assault, including lack of signed and dated statements and incomplete interviews.
Failed to timely report suspected abuse to DHSS within the two-hour required timeframe and failed to notify local law enforcement.
Report Facts
Facility census: 69
Days to complete investigation: 5
Date of resident's quarterly MDS assessment: Oct 31, 2024
Date of facility investigation report: Jan 14, 2025
Date survey completed: Jan 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Reported the resident's allegation and was interviewed about the investigation process |
| Director of Nursing | Director of Nursing (DON) | Conducted the investigation and was interviewed regarding the handling of the allegation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about awareness of the allegation and reporting requirements |
| Administrator | Facility Administrator | Interviewed about the investigation and reporting process |
Inspection Report
Routine
Census: 66
Deficiencies: 9
Date: Aug 9, 2024
Visit Reason
Routine inspection to evaluate compliance with regulatory requirements including PASARR screening, food and nutrition services, infection prevention, and food safety.
Findings
The facility failed to complete required Level I Pre-admission Screening (PASARR) for sampled residents, did not employ a qualified full-time dietitian or director of food and nutrition services, failed to serve food according to menus and at safe temperatures, and had multiple food safety and hygiene violations. Additionally, the facility lacked a designated qualified infection preventionist.
Deficiencies (9)
Failed to ensure Level I Pre-admission Screening (PASARR) was completed for three of seven sampled residents.
Failed to designate a qualified Director of Food and Nutrition Services when no qualified dietitian or nutrition professional was employed full-time.
Failed to serve food in accordance with nutritionally calculated menus to all residents.
Failed to ensure prepared food items were served at safe and appetizing temperatures; hot foods were below required temperatures and pureed foods were not reheated properly.
Failed to prepare and serve food items at appropriate texture for residents on dental/mechanical soft diets.
Failed to store food properly to prevent contamination and outdated use, including unlabeled, undated, uncovered foods and improper thawing practices.
Failed to allow sanitized dishes to air dry before stacking and failed to cover kitchen waste containers when not in use.
Failed to perform hand hygiene as often as necessary and properly, including improper glove use and handwashing technique.
Failed to designate a qualified infection preventionist for the facility's infection prevention and control program.
Report Facts
Residents affected: 3
Facility census: 66
Residents affected: 10
Food items unlabeled/undated: 12
Food items unlabeled/undated: 6
Food items unlabeled/undated: 16
Food storage violations: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA H | Dietary Aide | Named in multiple food handling and hygiene violations including failure to check food temperatures and improper hand hygiene |
| DM | Dietary Manager | Named in food service management deficiencies, training staff improperly on food preparation and hygiene |
| LPN/ADON | Licensed Practical Nurse/Assistant Director of Nursing | Named as not yet trained infection preventionist |
| Administrator | Provided statements on facility staffing, training, and deficiencies | |
| DA I | Dietary Aide | Observed stacking wet dishes and improper dish handling |
| F | Cook | Observed preparing food improperly and not following recipes |
| G | Cook | Observed preparing food improperly and not following recipes |
Inspection Report
Routine
Census: 68
Deficiencies: 10
Date: May 19, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, assistance with activities of daily living, pressure ulcer care, accident hazard prevention, medication storage and administration, food preparation and storage, infection control, and immunization procedures at the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to obtain and document resident weights, inadequate assistance with grooming, bathing, and meals, improper pressure ulcer care, unsafe wheelchair use, unsafe medication storage and administration practices, failure to follow food preparation and storage standards, poor kitchen sanitation, inadequate infection control practices, and failure to maintain and follow pneumococcal vaccination procedures.
Deficiencies (10)
Facility staff failed to obtain and document weights for four residents (#12, #20, #30, and #67).
Facility staff failed to assist dependent residents with grooming, bathing, and meals as required.
Facility staff failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident (#9).
Facility staff failed to ensure the resident's environment remained free of accident hazards including improper wheelchair use and unsafe mechanical lift transfers.
Facility staff failed to store and label medication in a safe and effective manner for two medication carts and one medication storage room.
Facility staff failed to prepare food according to recipes and ensure residents with pureed diets received all items on the menu.
Facility staff failed to ensure the ice machine drained through an air gap, properly store open food to prevent cross contamination and outdated usage, and maintain the kitchen in a clean and sanitary manner. Staff also failed to perform hand hygiene as often as necessary.
Facility staff failed to use appropriate infection control procedures to prevent spread of infection during incontinence care and medication administration.
Facility staff failed to maintain and follow current guidance and procedures for pneumococcal pneumonia immunizations for four residents.
Facility failed to ensure the Director of Nurses did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents.
Report Facts
Residents affected: 4
Residents affected: 8
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 10
Residents affected: 4
Facility census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT L | Certified Medication Technician | Named in medication storage and administration deficiencies |
| LPN F | Licensed Practical Nurse | Named in infection control and wheelchair safety deficiencies |
| DON | Director of Nursing | Named in multiple findings including wound care, infection control, and staffing |
| Administrator | Named in staffing and infection control deficiencies | |
| DM | Dietary Manager | Named in food preparation, storage, and kitchen sanitation deficiencies |
| CNA B | Certified Nurse Aide | Named in infection control and wheelchair safety deficiencies |
| CNA E | Certified Nurse Aide | Named in infection control and wheelchair safety deficiencies |
| CNA N | Certified Nurse Aide | Named in wheelchair safety deficiencies |
| CNA A | Certified Nurse Aide | Named in wheelchair safety deficiencies |
| [NAME] M | Cook | Named in food preparation and kitchen sanitation deficiencies |
Inspection Report
Routine
Census: 68
Deficiencies: 2
Date: May 19, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing care and assistance to residents unable to perform activities of daily living, including grooming, bathing, and meal assistance.
Findings
The facility staff failed to assist multiple dependent residents with grooming, bathing, and meals as required by their care plans and facility policies. Observations and record reviews showed inadequate assistance with showers and meal support, with several residents observed with poor hygiene and lack of meal assistance.
Deficiencies (2)
Failed to assist five out of 17 sampled dependent residents with grooming and bathing.
Failed to assist three dependent residents during meals.
Report Facts
Residents affected: 8
Facility census: 68
Shower assistance documented: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Assistant | Interviewed regarding shower documentation and frequency |
| LPN G | Licensed Practical Nurse | Interviewed about shower documentation and resident care |
| LPN F | Licensed Practical Nurse | Interviewed about shower frequency and meal assistance expectations |
| CNA B | Certified Nurse Assistant | Interviewed about shower frequency and documentation |
| NA H | Nurse Assistant | Interviewed about shower frequency and documentation |
| Director of Nursing (DON) | Director of Nursing | Interviewed about shower frequency and documentation |
| Administrator | Administrator | Interviewed about shower frequency and meal assistance expectations |
| CNA E | Certified Nurse Assistant | Interviewed about meal assistance and opening condiments |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Mar 25, 2023
Visit Reason
The inspection was conducted following a complaint regarding sexual abuse when Resident #2 was observed touching Resident #1 inappropriately on 3/25/2023 at approximately 8:00 P.M.
Complaint Details
The complaint was substantiated as facility staff observed Resident #2 with his/her hand down Resident #1's pants in a sexual act. Both residents were placed on 15-minute face checks, family and physician were notified, and psychiatric evaluation was conducted for Resident #2.
Findings
Facility staff failed to ensure Resident #1 remained free from sexual abuse by Resident #2. Both residents were separated and placed on 15-minute checks. Staff updated assessments, notified appropriate parties, and Resident #2 received a psychiatric evaluation. Staff were in-serviced on interventions, and the deficient practice was corrected on 3/25/2023.
Deficiencies (1)
Failed to protect Resident #1 from sexual abuse by Resident #2.
Report Facts
Facility census: 71
15-minute checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) B | Reported both residents remained on 15-minute checks until further notice | |
| Administrator | Notified of incident and stated residents would continue on 15-minute checks until review | |
| Licensed Practical Nurse (LPN) C | Reported no prior witnessed sexual behaviors by Resident #2 | |
| Licensed Practical Nurse (LPN) D | Observed incident, separated residents, notified administrator, and made facility self report | |
| Certified Nursing Assistant (CNA) E | Assisted with residents during incident and reported no prior witnessed sexual behaviors by Resident #2 |
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 10
Date: Oct 15, 2021
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements including resident care, medication administration, safety, infection control, and food service.
Findings
The facility was found deficient in multiple areas including failure to post ombudsman information, medication administration errors, inadequate assistance with activities of daily living, unsafe wheelchair use, incomplete side rail assessments and documentation, incomplete nurse staffing logs, expired and unlabeled medications, improper food service and storage practices, and lapses in infection prevention and control procedures.
Deficiencies (10)
Facility staff failed to post the name, address and phone number for the Long-Term Care Ombudsman in a form and manner accessible to residents.
Licensed staff failed to maintain professional standards by administering medication and leaving the room prior to verifying residents took their medications for 3 of 9 sampled residents.
Facility staff failed to provide assistance with activities of daily living for 5 of 20 sampled residents requiring help with bathing, dressing, and grooming.
Facility staff failed to ensure safe wheelchair use for 7 of 20 sampled residents by not using foot pedals and failed to keep walkways free of obstacles for one resident; also left an unidentified pill on a dining area shelf.
Facility staff failed to complete required side rail assessments, entrapment assessments, obtain physician orders, and update care plans for multiple residents using side rails.
Facility staff failed to maintain daily nurse staffing schedule logs for the required eighteen months.
Facility staff failed to discard expired medications and properly label medications with expiration dates.
Facility staff failed to serve food items in accordance with the nutritionally calculated menus for all diet types and failed to have current menus available for food service staff.
Facility staff failed to allow sanitized kitchenware to air dry before storage or use, failed to wash hands appropriately, failed to maintain kitchen equipment and food storage in a sanitary manner, failed to clean and sanitize food contact surfaces properly, and failed to store moist cleaning cloths in sanitizing solution between uses.
Facility staff failed to use appropriate infection control procedures including catheter care, perineal care, hand hygiene, and disinfecting blood glucose monitors between uses.
Report Facts
Facility census: 68
Medication error rate: 11.11
Days missing nurse staffing logs: 17
Days missing nurse staffing logs: 10
Days missing nurse staffing logs: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT H | Certified Medical Technician | Named in medication administration and hand hygiene findings |
| LPN W | Licensed Practical Nurse | Named in medication administration and medication policy interview |
| CNA E | Certified Nursing Assistant | Named in perineal care and catheter care findings |
| Director of Nursing | Director of Nursing | Named in medication administration, infection control, and catheter care findings |
| Administrator | Facility Administrator | Named in wheelchair safety, side rail assessments, nurse staffing logs, food service, and infection control findings |
| Dietary Manager | Dietary Manager | Named in food service and kitchen sanitation findings |
| CMT I | Certified Medical Technician | Named in medication administration and blood glucose monitor cleaning findings |
| CNA F | Certified Nursing Assistant | Named in hand hygiene findings |
| LPN O | Licensed Practical Nurse | Named in medication administration, catheter care, and hand hygiene findings |
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