Deficiencies (last 7 years)
Deficiencies (over 7 years)
18.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
244% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
57% occupied
Based on a July 2025 inspection.
Occupancy rate 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
Complaint Investigation
Census: 69
Deficiencies: 4
Date: Jan 22, 2025
Visit Reason
The inspection was conducted due to an allegation of sexual assault involving one resident. The facility was investigated for compliance with abuse, neglect, and exploitation policies and reporting requirements.
Complaint Details
The investigation was triggered by a complaint alleging sexual assault of Resident #1. The allegation was not substantiated as the facility's internal investigation did not reveal abuse, but the facility failed to follow required investigation and reporting procedures.
Findings
The facility failed to thoroughly investigate the allegation of sexual assault and did not obtain signed and dated witness statements or document interviews with other residents. The facility also failed to report the allegation to local law enforcement and the Department of Health and Senior Services (DHSS) within the required two-hour timeframe.
Deficiencies (4)
F607: The facility failed to develop and implement adequate abuse and neglect policies and failed to thoroughly investigate an allegation of sexual assault for one resident.
F609: The facility failed to report alleged violations of abuse and neglect to local law enforcement and DHSS within the required two-hour timeframe for one resident.
A8023: The facility did not develop and implement policies prohibiting mistreatment, neglect, and abuse of residents as required by state regulations.
A8025: The facility failed to report abuse or neglect to DHSS/DMH as required when there is reasonable cause to believe a resident has been abused or neglected.
Report Facts
Facility census: 69
Compliance plan completion date: Compliance to be achieved by February 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John McBryant | Administrator | Signed the inspection report and plan of correction |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed during investigation; did not provide signed statement |
| Director of Nursing | Director of Nursing (DON) | Interviewed and documented investigation; did not report to DHSS within required timeframe |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding reporting and investigation procedures |
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
Annual Inspection
Census: 66
Deficiencies: 7
Date: Aug 9, 2024
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for Stonebridge Villa Marie nursing facility.
Findings
The facility was found deficient in multiple areas including PASARR screening for mental disorders and intellectual disabilities, staffing of qualified dietary personnel, menu planning and food service, food safety and sanitation, infection preventionist qualifications, and food procurement and storage practices.
Deficiencies (7)
F645 PASARR Screening for MD & ID: Facility staff failed to ensure Level I Pre-Admission Screening and Resident Review (PASARR) level II screens were completed for three of seven sampled residents. The facility census was 66.
F801 Qualified Dietary Staff: Facility staff failed to designate a qualified dietary manager with appropriate qualifications and failed to employ a full-time qualified dietitian or clinically qualified nutrition professional. The facility census was 66.
F803 Menus Meet Resident Needs/Preparation/Followed: Facility staff failed to serve food in accordance with nutritionally calculated menus and failed to follow menus for mechanical soft and pureed diets. The facility census was 66.
F804 Nutritive Value/Appearance/Palatable/Preferred Temp: Facility staff failed to serve prepared food items at safe and appetizing temperatures and failed to maintain internal temperatures of hot food items. The facility census was 66.
F805 Food in Form to Meet Individual Needs: Facility staff failed to prepare and serve food items at appropriate textures for 10 residents receiving dental/mechanical soft diets. The facility census was 52.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility staff failed to store food to prevent contamination, failed to maintain proper food temperatures, and failed to label and date foods properly. The facility census was 66.
F882 Infection Preventionist Qualifications/Role: Facility staff failed to designate a qualified infection preventionist and failed to provide required training. The facility census was 66.
Report Facts
Facility census: 66
Facility census: 52
Number of sampled residents: 7
Number of residents with incomplete PASARR screening: 3
Inspection Report
Life Safety
Census: 66
Capacity: 120
Deficiencies: 4
Date: Aug 9, 2024
Visit Reason
The inspection was conducted to evaluate compliance with emergency preparedness and fire safety regulations, including review of the Emergency Preparedness Plan (EPP) and fire drill procedures.
Findings
The facility failed to ensure the Emergency Preparedness Plan included policies for subsistence needs and alternate energy sources to maintain safe temperatures and emergency systems. The facility also failed to conduct fire drills at various times and under varying conditions quarterly as required, and did not document simulated fire conditions for some drills.
Deficiencies (4)
E015: The facility's Emergency Preparedness Plan lacked policies and procedures for subsistence needs and alternate energy sources to maintain safe temperatures, emergency lighting, fire detection, extinguishing, and alarm systems during emergencies.
K712: The facility failed to conduct fire drills quarterly on each shift at varying times and conditions from August 2023 through July 2024, and did not document simulated fire conditions for drills dated 08/21/23 and 09/26/23.
A2058: The facility did not have a written fire drill and emergency preparedness plan meeting state requirements, including annual consultation with local fire units and emergency management.
A2061: The facility failed to conduct a minimum of twelve fire drills annually with at least one every three months on each shift, including unannounced drills and simulated resident evacuations involving local fire or emergency services.
Report Facts
Facility census: 66
Facility capacity: 120
Fire drills conducted: 8
Fire drills required annually: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding Emergency Preparedness Plan and fire drills; stated lack of knowledge about missing policies and fire drill requirements | |
| Maintenance Director | Interviewed regarding responsibility for fire drills and documentation; acknowledged some drills were not conducted as required | |
| Director of Clinical and Operations | Completed education for Administrator on Emergency Operations Plan |
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
Plan of Correction
Census: 68
Deficiencies: 10
Date: May 19, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Stonebridge Villa Marie, detailing regulatory findings from a survey conducted on 05/19/2023 and the facility's plan to address these deficiencies.
Findings
The facility was found deficient in multiple areas including failure to meet professional standards in comprehensive care plans, inadequate assistance with activities of daily living, failure to prevent pressure ulcers, improper medication storage and administration, food safety violations, infection control lapses, and insufficient nursing staff coverage. The facility census was consistently reported as 68 during the survey.
Deficiencies (10)
F658 Comprehensive Care Plans: Facility staff failed to obtain and document weights for four residents and did not meet professional standards of care.
F677 ADL Care Provided for Dependent Residents: Staff failed to assist multiple dependent residents with grooming, bathing, and meal assistance as required.
F686 Pressure Ulcer Prevention/Treatment: Facility staff failed to plan interventions, complete Braden scale assessments, document weekly skin assessments, and consult dietitian for pressure ulcer care.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision and safe mechanical lift transfers.
F727 RN 8 Hrs/7 days/Wk, Full Time DON: Facility failed to ensure the Director of Nursing worked as charge nurse when census exceeded 60 residents.
F761 Label/Store Drugs and Biologicals: Facility failed to store and label medications properly and failed to maintain medication storage safety.
F803 Menus Meet Resident Needs/Prep in Advance/Followed: Facility failed to prepare food according to recipes and ensure residents received all menu items.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to maintain kitchen and food storage areas in a clean and sanitary manner.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention and control program including hand hygiene and catheter care.
F883 Influenza and Pneumococcal Immunizations: Facility failed to maintain current immunization records and provide education and immunizations as required.
Report Facts
Facility census: 68
Number of residents with weight documentation issues: 4
Number of dependent residents not assisted with ADLs: 5
Number of dependent residents not assisted during meals: 3
Number of residents with pressure ulcer assessment failures: 10
Number of residents with accident hazard supervision failures: 5
Director of Nursing charge nurse coverage threshold: 60
Inspection Report
Life Safety
Census: 68
Capacity: 120
Deficiencies: 17
Date: May 19, 2023
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety regulations and related codes at Stonebridge Villa Marie.
Findings
The facility failed to maintain egress doors free of impediments, ensure proper operation and testing of fire alarm and sprinkler systems, and maintain smoke barriers and fire doors. Several deficiencies were noted related to delayed egress doors, fire alarm testing documentation, sprinkler system maintenance, electrical equipment, and storage of combustible materials.
Deficiencies (17)
K222 Egress Doors: The facility failed to maintain egress doors free of impediments and ensure delayed egress doors operated properly, affecting six of seven smoke zones.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to ensure 100% inspection and testing of the fire alarm system and maintain complete documentation.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads free of foreign materials and provide complete inspection documentation.
K363 Corridor - Doors: The facility failed to ensure corridor doors positively latched and resisted smoke passage in three of seven smoke zones.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke and fire barrier walls, affecting four of seven smoke zones.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to maintain electrical wiring and extension cords in compliance with code requirements.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to ensure combustible materials were not stored near gas equipment and maintain proper oxygen storage.
A1065 Drinking Fountains: The facility failed to provide accessible drinking fountains in required locations.
A2010 Oxygen Storage: The facility failed to comply with NFPA 99 requirements for oxygen storage safety.
A2019 Fire Alarm System-Test/Maintain: The facility failed to maintain a complete fire alarm system in accordance with NFPA 72.
A2020 Fire Alarm System-Inspections/Certifications: The facility failed to maintain complete fire alarm inspection and certification records.
A2034 Sprinkler System-Test/Maintain: The facility failed to maintain sprinkler system testing and maintenance in accordance with code.
A2035 Complete Sprinkler System: The facility failed to maintain a complete sprinkler system per NFPA 13 requirements.
A2037 Exit Requirements: The facility failed to maintain required exits in an existing multi-story facility.
A2054 Smoke Section Walls/Doors: The facility failed to maintain fire-rated smoke section walls and doors.
A3037 Extension Cords/Duplex Receptacles: The facility failed to comply with electrical code requirements for extension cords and receptacles.
A6040 Outside Openings Protected Against Rodents: The facility failed to provide routine maintenance to protect against rodent entry.
Report Facts
Facility census: 68
Facility capacity: 120
Facility census: 69
Facility capacity: 102
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Mar 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of sexual abuse between two residents.
Complaint Details
The complaint investigation was substantiated based on staff observations and interviews confirming inappropriate sexual contact between residents. The facility implemented corrective actions including 15-minute checks and staff in-service training.
Findings
The facility failed to ensure one resident remained free from sexual abuse when another resident touched them inappropriately. Staff observed the incident, separated the residents, and implemented 15-minute checks, but documentation and interventions were initially insufficient.
Deficiencies (1)
F 600 Freedom from Abuse and Neglect: The facility failed to prevent sexual abuse when Resident #2 touched Resident #1 inappropriately. Staff did not initially document interventions or monitor the sexual behaviors adequately.
Report Facts
Facility census: 71
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
Plan of Correction
Census: 66
Deficiencies: 2
Date: Jan 23, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to professional standards in medication administration and protective oversight for residents, specifically focusing on narcotic pain patch management and voluntary leave procedures.
Findings
The facility failed to meet professional standards in medication administration, including improper removal and documentation of narcotic pain patches for a resident. Additionally, the facility did not meet requirements for protective oversight during residents' voluntary leave.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) The facility staff failed to follow professional standards by not removing one resident's fentanyl patches prior to administering new ones and failing to transcribe the correct physician ordered medication to the Medication Administration Record. The facility census was 66.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave The facility did not have a procedure to inquire of the resident or guardian about the resident's departure, estimated length of absence, or whereabouts while on voluntary leave.
Report Facts
Facility census: 66
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 12
Date: Oct 15, 2021
Visit Reason
Annual inspection survey conducted on 10/15/2021 to assess compliance with state and federal regulations for Stonebridge Villa Marie nursing facility.
Findings
The facility was found non-compliant with multiple regulatory requirements including failure to post required Long-Term Care Ombudsman information, medication administration errors, inadequate assistance with activities of daily living, unsafe environment hazards, improper use and assessment of bed rails, medication labeling and storage issues, infection control deficiencies, and food safety violations.
Deficiencies (12)
F575 Required Postings. The facility failed to post the name, address, and phone number for the Long-Term Care Ombudsman in a form accessible to residents.
F658 Services Provided Meet Professional Standards. Licensed staff failed to maintain professional standards by improperly administering medication and leaving the room before verifying residents took their medications.
F677 ADL Care Provided for Dependent Residents. Facility staff failed to provide necessary assistance with activities of daily living for five sampled residents requiring help with bathing, grooming, and dressing.
F689 Free of Accident Hazards/Supervision/Devices. Facility failed to ensure residents' environment was free of accident hazards and did not properly supervise or assist residents, leading to unsafe conditions.
F700 Bedrails. Facility failed to complete required side rail assessments, entrapment assessments, and obtain physician orders for residents using bed rails.
F732 Posted Nurse Staffing Information. Facility failed to maintain and post daily nurse staffing information for a minimum of 18 months as required.
F759 Free of Medication Error Rts 5 Prcnt or More. Facility failed to maintain medication error rate below 5%, with an 11.11% error rate observed.
F761 Label/Store Drugs and Biologicals. Facility failed to discard expired medications and properly label medications with expiration dates.
F803 Menus Meet Resident Nds/Prep in Adv/Followed. Facility failed to serve food items in accordance with nutritional guidelines and failed to maintain proper food storage and sanitation.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. Facility failed to ensure food safety requirements including proper cleaning, sanitizing, and storage of food and kitchen equipment.
F835 Bedrails. Facility failed to maintain policies and procedures for bedrail use and failed to re-educate staff on bedrail safety.
F880 Infection Prevention & Control. Facility failed to establish and maintain an effective infection prevention and control program including hand hygiene and environmental cleaning.
Report Facts
Facility census: 68
Medication error rate: 11.11
Medication opportunities observed: 27
Medication errors: 3
Completion date: 2021
Inspection Report
Life Safety
Census: 68
Capacity: 120
Deficiencies: 6
Date: Oct 15, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations, including sprinkler system maintenance, fire door inspections, emergency power systems, and night light requirements.
Findings
The facility failed to meet several Life Safety Code requirements, including missing sprinkler escutcheon plates, unsealed ceiling penetrations, missing or inadequate Fire Department Connection signage, failure to inspect and maintain nonrated egress doors, and lack of documentation for emergency power system inspections. Night lights in resident rooms and common areas were also found nonfunctional.
Deficiencies (6)
K353 Sprinkler system maintenance and testing deficiencies included missing escutcheon plates, unsealed ceiling penetrations, missing ceiling tiles, and inadequate Fire Department Connection signage. These issues pose a risk of delayed sprinkler response and fire spread.
K761 Facility staff failed to inspect, test, and maintain nonrated egress doors according to the 2012 NFPA 101 Life Safety Code. Documentation of inspections was incomplete or missing.
K918 The emergency power system lacked a remote manual stop station, and documentation for generator inspections did not address this deficiency. This affects the facility's ability to safely manage emergency power.
A1132 Facility failed to provide required night lights in hallways, individual toilet rooms, stairways, and resident rooms or adjacent toilet rooms. Several night lights were nonfunctional during inspection.
A1135 Emergency lighting for exits, stairs, corridors, and nurse stations was not maintained as required by NFPA 99 and related codes. The facility failed to ensure emergency lighting was operational.
A2034 Sprinkler system inspection, maintenance, and testing requirements were not met as per regulations for facilities with sprinkler systems installed prior to August 28, 2007.
Report Facts
Facility census: 68
Total capacity: 120
Deficiencies cited: 6
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 |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 28, 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: Oct 27, 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
Plan of Correction
Census: 68
Deficiencies: 2
Date: Oct 21, 2020
Visit Reason
The inspection was conducted to assess infection prevention and control practices related to COVID-19 at Villa Marie-A Stonebridge Community, including compliance with isolation procedures and PPE usage during the COVID-19 outbreak.
Findings
The facility failed to use appropriate infection control procedures to prevent the spread of COVID-19, including improper use and reuse of isolation gowns and failure to separate COVID-19 positive and negative residents. Staff were observed not following proper PPE protocols and residents were not consistently quarantined or masked.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to implement effective infection control procedures to prevent the spread of COVID-19, including improper isolation gown use and failure to separate COVID-19 positive and negative residents.
A4085 Infection Control/Communicable Disease: The facility did not report communicable diseases to the state within seven days as required by Missouri regulations.
Report Facts
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharyl Berthnot | LNHA | Signed the plan of correction document |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Date: Jun 15, 2020
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess compliance with infection prevention and control protocols related to COVID-19.
Complaint Details
The investigation was complaint-related focusing on COVID-19 infection control practices. The facility was found noncompliant with CDC and CMS guidelines for infection prevention.
Findings
The facility failed to follow infection control protocols for COVID-19, including failure to maintain social distancing, improper use of facemasks by staff and residents, and inadequate hand hygiene and sanitizing practices.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to follow infection control protocols for COVID-19, including failure to maintain social distancing, improper use of facemasks by staff and residents, and inadequate hand hygiene and sanitizing practices.
A4085 Infection Control/Communicable Disease: Residents shall be cared for using acceptable infection control procedures to prevent spread of infection. The facility failed to meet this regulation as evidenced by the F880 findings.
Report Facts
Census: 73
Plan of Correction Completion Date: Aug 3, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Berhorst | Administrator | Named in observations related to failure to wear facemask and social distancing |
| Director of Nursing | Named in observations and interviews regarding mask wearing and social distancing | |
| Registered Nurse B | Registered Nurse | Interviewed regarding staff mask and hand hygiene expectations |
| Housekeeper A | Observed failing to wash or sanitize hands after contact with resident | |
| Activity Aide C | Observed failing to sanitize bean bag between residents | |
| Dietary Aide D | Interviewed regarding mask wearing expectations | |
| Certified Nursing Assistant F | Observed wearing mask improperly and interviewed about PPE training |
Inspection Report
Plan of Correction
Census: 77
Deficiencies: 1
Date: Jan 31, 2020
Visit Reason
The inspection was conducted to investigate compliance with notification requirements related to significant changes in a resident's condition, specifically regarding failure to notify the resident's family of such changes.
Findings
The facility failed to notify the family of a resident with a significant change in condition as required by federal regulations. Interviews and record reviews confirmed the lack of timely notification despite policies and directives.
Deficiencies (1)
F580 Notification of Changes. The facility failed to immediately inform the resident's family of a significant change in the resident's physical, mental, or psychosocial status as required by regulation.
Report Facts
Facility census: 77
Inspection Report
Plan of Correction
Census: 70
Deficiencies: 9
Date: Aug 19, 2019
Visit Reason
The document is a Plan of Correction submitted by Villa Marie-A Stonebridge Community following a federal inspection completed on 2019-08-19. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including comprehensive resident assessments, quarterly assessments, accuracy of assessments, hygiene and personal care, food safety, bed rail safety, and sufficient nursing staff. The facility census was 70 at the time of inspection.
Deficiencies (9)
F636: Facility failed to complete federally required comprehensive Minimum Data Set (MDS) assessments for three residents in a timely manner.
F638: Facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed for 27 residents as required.
F641: Facility failed to accurately code the Minimum Data Set (MDS) for three residents, including failure to document significant weight loss.
F677: Facility failed to meet hygiene needs for six dependent residents, including failure to document showers and skin checks.
F688: Facility failed to ensure residents received appropriate restorative nursing care to prevent decrease in range of motion (ROM).
F700: Facility failed to properly install and maintain bed rails, and failed to complete entrapment assessments for four residents.
F725: Facility failed to provide sufficient nursing staff to meet residents' hygiene needs and complete required assessments.
F812: Facility failed to comply with food safety requirements including proper handwashing, food storage, and sanitation procedures.
F909: Facility failed to complete bed rail safety checks and entrapment assessments for residents, and failed to monitor use of side rails.
Report Facts
Facility census: 70
Residents with incomplete quarterly MDS assessments: 27
Residents with bed rail entrapment assessments not completed: 4
Residents with side rails assessed: 4
Residents with hygiene needs unmet: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Burkhart | Administrator | Signed the Plan of Correction and is responsible for oversight |
| Director of Nursing | Named in interviews regarding MDS assessments and staffing | |
| MDS Coordinator | Named in interviews regarding MDS assessment completion and accuracy | |
| Certified Nurse Assistant (CNA) D | Interviewed regarding shower aide availability and resident care | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding resident care and shower scheduling | |
| Physical Therapist (PT) H | Interviewed regarding restorative nursing program | |
| Certified Dietary Manager (CDM) | Interviewed and observed regarding food safety and sanitation |
Inspection Report
Life Safety
Census: 70
Capacity: 120
Deficiencies: 4
Date: Aug 19, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain exit corridors free of obstructions and unsecured furniture, failed to provide visible signage for delayed-egress locking devices, and did not maintain two smoking areas free from fire hazards. Additionally, the facility lacked complete documentation for electrical system inspections and testing.
Deficiencies (4)
K211 Means of Egress - General: Facility staff failed to maintain exit corridors free of obstruction and unsecured furniture, which could delay evacuation in an emergency.
K222 Egress Doors: Facility staff failed to maintain doors with delayed-egress locking devices with visible, durable signage and failed to maintain doors readily accessible at all times.
K741 Smoking Regulations: Facility staff failed to maintain two smoking areas free from fire hazards and ensure proper disposal of cigarette waste in metal self-closing containers.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Facility staff failed to provide complete and verifiable documentation of annual main and feeder circuit breaker inspections and testing.
Report Facts
Facility census: 70
Facility capacity: 120
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 10
Date: Sep 13, 2018
Visit Reason
Annual survey inspection of Villa Marie-A Stonebridge Community to assess compliance with state and federal regulations.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident funds in interest-bearing accounts, inadequate maintenance of a safe and homelike environment, failure to properly check employee backgrounds, incomplete resident care plans, and failure to provide timely pneumococcal and influenza vaccinations.
Deficiencies (10)
F567: Facility failed to deposit resident funds in excess of $100 in an interest-bearing account and did not allow withdrawals over $50 as required. This affected fourteen residents and the facility census was 70.
F584: Facility failed to provide a safe, clean, comfortable, and homelike environment, including failure to repair peeling baseboards, sticky floors, and damaged closet doors in multiple resident rooms. The facility census was 70.
F606: Facility failed to conduct criminal background checks and employee disqualification list checks for newly hired staff prior to hire, including CNA, LPN, and Social Service Director. The facility census was 70.
F623: Facility failed to provide written notices of transfer/discharge to residents and their representatives, including failure to notify the Ombudsman for one resident with two facility-initiated discharges. The facility census was 70.
F656: Facility failed to develop comprehensive care plans with measurable goals and interventions for six of eighteen sampled residents. The facility census was 70.
F657: Facility failed to update care plans timely after significant changes, including falls and injuries for multiple residents. The facility census was 70.
F677: Facility failed to provide timely incontinence care for three residents requiring incontinent care weekly. The facility census was 70.
F700: Facility failed to properly assess and maintain bed rails for five residents, increasing risk of injury. The facility census was 70.
F756: Facility failed to conduct monthly drug regimen reviews to identify and address medication irregularities for three residents. The facility census was 70.
F883: Facility failed to ensure pneumococcal vaccinations were offered and administered according to CDC guidelines for all residents. The facility census was 70.
Report Facts
Facility census: 70
Number of residents affected: 14
Number of residents sampled: 18
Number of residents with incomplete care plans: 6
Number of residents assessed for bed rails: 5
Number of residents requiring incontinent care weekly: 3
Number of residents reviewed for medication irregularities: 3
Number of residents offered pneumococcal vaccine: 5
Inspection Report
Annual Inspection
Census: 70
Capacity: 120
Deficiencies: 5
Date: Sep 13, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with emergency preparedness, life safety code, and electrical system maintenance requirements.
Findings
The facility failed to conduct a full-scale community-based emergency exercise and did not maintain documentation of such exercises. Additionally, the facility did not inspect and maintain fire doors and electrical receptacles at resident bed locations as required by applicable codes.
Deficiencies (5)
E039 Testing Requirements: The facility failed to participate in a full-scale community-based emergency exercise and did not document attempts to contact state or local agencies for such exercises.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to inspect, test, and maintain fire doors and non-rated doors in the means of egress for the period October 2017 through September 2018.
K914 Electrical Systems - Maintenance and Testing: Facility staff failed to assess electrical receptacles at resident bed locations for physical integrity, grounding circuit continuity, polarity, and retention force.
A1133 Electrical System-Test/Certify per Code: The facility did not have evidence of a qualified electrician testing and certifying the entire electrical system as required.
A2058 Fire Drill/Emergency Preparedness - Plans: The facility lacked a written plan to meet potential emergencies and disasters and failed to request consultation and assistance annually from a local fire unit.
Report Facts
Facility census: 70
Total capacity: 120
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