Stonebridge Florissant

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had access to mail delivered on Saturday. This failure had the potential to affect all residents who received mail at the facility. The census was 66. During a group interview on 8/20/25 at approximately 9:45 A.M., five residents, whom the facility identified as alert and oriented, attended the group meeting. All five residents said mail was no longer delivered on Saturdays. The mail is placed in the office, which was closed on the weekends, then distributed to the residents on Monday. One resident said this was frustrating because packages often arrive, and they can't access it until Monday. During an interview on 8/22/25 at 10:37 A.M., the Activity Director initially said mail was delivered on Saturdays and distributed as it arrived. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 66. Review of the facility's Daily Census, dated 8/17/25, showed:-Available beds: 109;-Percent of occupancy: 61.5%. Review of the facility's payroll-based journal (PBJ) report, showed:-No RN hours on Saturday, 1/11/25;-No RN hours on Sunday, 1/12/25;-No RN hours on Saturday, 1/25/25;-No RN hours on Sunday, 3/9/25. During an interview on 8/20/25 at 12:30 P.M., the Administrator said the facility did not have any documentation or time sheets to show the facility had an RN on the days listed on the PBJ report. During an interview on 8/22/25 at 3:13 P.M., the Administrator said he expected to have an RN in the facility at least eight consecutive hours a day, seven days a week.

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected two of three sampled residents who expired and had money in their accounts (Residents #74 and #75). The sample size was 17. The census was 66. Review of the facility's Resident Trust Fund Account Policy and Procedure, revised 2/2025, showed:-Policy: It is the policy of the facility to manage personal funds of our residents, upon request, and written authorization of the resident or legal representative. Funds will be managed in accordance with Federal and State Regulations;-Procedure: Upon the death of a resident with a balance in the Resident Trust Fund, the facility will complete a form and submit to Department of Social Services, Missouri Healthnet Division. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the notice of the bed hold at the time of transfer to the hospital for two of 17 sampled residents (Residents #68 and #32). The census was 66. Review of the facility's Bed Hold policy, dated October, 2017, showed:-Policy Statement: Our facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy. Bed hold status exists when a resident temporarily leaves the facility for medical or other therapeutic reasons and their return is anticipated. Hospitalizations are examples of leaves;-Policy Interpretation and Implementation; [...]

Inspectors wroteBased on interview and record review, the facility failed to document physician orders were verified for one resident (Resident #74) admitted for respite care. The sample was 17. The census was 66. Review of the facility's Admissions and admission Agreement Policy, dated February 2025, showed: Prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: medication orders, including (as necessary) a medical condition or problem associated with each medication; and routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received care consistent with professional standards when staff failed to do neurological check (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) after an unwitnessed fall for one resident (Resident #74). The sample was 17. The census was 66. Review of the facility's Fall policy, dated revised April 2022, showed:-The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen and any observations of the events, etc. Review of the facility's Neurological Assessment policy, dated revised October 2010, showed:-Purpose: the purpose of this procedure is to provide guidelines for neurological assessment: when following an unwitnessed fall;-General guidelines: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice, when staff failed to document a thorough assessment of a wound weekly and failed to transcribe treatment order for another wound when the resident returned from the hospital for one resident (Resident #33). The sample was 17. The census was 66. Review of the Wound Care policy, dated revised October 2018, showed:-Documentation: the following information should be recorded in the resident's medical record, if the resident refused the treatment and the reason(s) why;-Reporting: Notify the supervisor if the resident refuses the wound care;-Report other information in accordance with facility policy and professional standards of practice. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary medications as ordered by the physician. In addition, they failed to notify and document the physician was made aware of the missed medications for one of 17 sampled residents (Resident #74). The census was 66. Review of the facility's Administering Medications Policy, dated revised December 2012, showed:-Medications shall be administered in a safe and timely manner, and as prescribed;-Medications must be administered in accordance with the orders, including any required time frame;-Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meals);-If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administrating the medication shall document appropriately in the clinical chart. [...]

Inspectors wroteBased on interview and record review, the facility failed to keep residents free of accidents and injuries when a Certified Nurse Assistant (CNA) left a resident (Resident #7) unattended, rolled to his/her side on a low air loss mattress (LAL, a mattress designed with a system of air cells that are constantly inflated and deflated to prevent and treat pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on skin)), causing the resident to fall out of his/her bed on to a fall mat. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement timely and appropriate interventions to prevent potential falls and injury for one resident (Resident #1) who had one fall mat next to the left side of the bed. Resident #1 had a fall from the right side of the bed that did not have a fall mat, which resulted in injury. The facility additionally failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice when the facility failed to complete post (after) fall 72 hour monitoring report (neurological (neuro) checks - pulse (P), respiration (R), and blood pressure (BP) measurements; assessment of pupil size and reactivity; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide eight hours of Registered Nurse (RN) coverage on 18 out of 38 days reviewed for staffing. This had the potential to cause unmet health needs for all residents. The census was 85. Review of the Nursing Services and Sufficient Staff Policy, dated revised 1/31/23, showed: -Except when waived, the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. Review of the facility's daily staffing patterns, dated 1/22/24 through 2/28/24, showed: -On 1/22/24, 1/23/24, 1/26/24, 1/27/24, 1/28/24, 1/30/24, 2/2/24, 2/6/24, 2/9/24, 2/10/24, 2/11/24, 2/13/24, 2/16/24, 2/20/24, 2/23/24, 2/24/24, 2/25/24 and 2/27/24, there was no RN coverage. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a water management program to reduce the growth/spread of Legionella (a bacterium that can live and grow in water systems and causes Legionnaires Disease (a severe form of pneumonia caused by Legionella bacteria)) and other opportunistic pathogens in the building's water system. This failure had the potential to affect all residents who reside in the facility. The sample was 24. The census was 85. Review of the facility's Water Management Policy, dated September 2022, showed: -Policy: It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards; -Definitions: - Legionellosis refers to two clinically and epidemiologically distinct illnesses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for residents when staff failed to ensure common areas were free from strong urine odors that did not dissipate throughout the investigative process. The census was 85. Review of the facility's Facility Responsibilities Policy, dated September 2022, showed: -Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment; -The facility will provide: a safe, clean, comfortable, and homelike environment, allowing the resident to use his/her personal belonging to the extent possible; -Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 2/22/24 at 8:35 A.M. and at 9:44 A.M., showed a large yellow soiled utility bin outside of room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs when one resident was observed with a soiled brief for an extended amount of time (Resident #46). In addition, the facility failed to provide showers for two residents (Residents #20 and #41) and failed to properly wash one resident's dentures (Resident #29). The sample size was 24. The census was 85. Review of the facility's ADL Care of the Resident Policy, revised December 2018, showed: -It is the policy of this facility to provide ADL care to residents to ensure needs are met daily; -Policy Explanation and Compliance Guidelines: -Each resident's physical functioning will be assessed in accordance with the facility's assessment procedures; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate and competent staffing to meet the needs of residents when call lights were not answered in a timely manner for residents, including Resident #46 and #41. The sample size was 24. The census was 85. Review of the facility's Nursing Services and Sufficient Staff Policy, dated revised 1/31/23, showed: -The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans; -Providing care includes, but is not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. Review of the facility's Facility Assessment, updated 1/19/24, showed: -The facility had two nursing units, an East and [NAME] wing; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified eight medication/treatment carts and two medication rooms. Four of the eight carts and one medication room were checked for medication storage. Issues were found in one medication room, two medication carts and one treatment cart. Staff failed to date an opened vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution, artificial tears (eye drops used to lubricate dry eyes and help keep moisture on the outer surface of eyes), and Miralax polyethylene glycol powder (used as a laxative to treat occasional constipation or irregular bowel movements). [...]

Inspectors wroteBased on interview and record review, the facility failed to explicitly inform the resident or his or her representative of their right not to sign an arbitration agreement (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) as a condition of admission, or as a requirement to continue to receive care at the facility, for three of 25 sampled residents (Residents #87, #82 and #26). The census was 85. Review of the facility's Arbitration Agreements Policy, dated September 2022, showed: -Policy: This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility; -Definition: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses and bed/side rails as a part of a regular maintenance program to identify areas of possible entrapment for four of 24 sampled residents (Residents #29, #61, #20 and #41). The census was 85. Review of the facility Proper use of Side Rails Policy, dated September 2022, showed; -Statement: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails; -Definitions: -Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to uphold one resident's rights (Resident #46) by turning off the resident's call light without providing assistance to the resident or notifying staff the resident needed assistance, resulting in the resident having to wait an extended amount of time before staff provided assistance. In addition, the facility failed to ensure a resident was treated with dignity when a staff member interacted inappropriately with a resident who required assistance with his/her clothing (Resident #40). The sample size was 24. The census was 85. Review of the facility's Resident Right's policy, dated September 2022, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized comprehensive care plans to address specific needs of the residents for three of 24 sampled residents (Residents #29, #26 and #41). The census was 85. Review of the facility Care Planning - Interdisciplinary Team Policy, revised [DATE], showed: -Policy: Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident; -A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff); -The policy failed to show when a care plan should be updated and failed to show who was responsible for updating the care plan. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner to prevent the risk of accidents and injury for one resident who was transferred using an unsafe technique (Resident #17). The census was 85. Review of the facility's Mechanical Lifting Machine Policy and Procedure, revised July 2017, showed: -The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions; -At least two nursing assistants are needed to safely move a resident with a mechanical lift; -Mechanical lifts may be used for tasks that require: -Lifting a resident from the floor; -Transferring a resident from bed to chair; -Lateral transfers; d- Lifting limbs; -Toileting or bathing; -Repositioning; -Types of lifts that may be available in the facility are: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #83), who received tube feeding (supplies liquid nutrition) through a gastronomy tube (g-tube, a tube that is placed directly into the stomach through an abdominal wall incision for the administration of food, fluids and medicine) received the appropriate treatment and services when staff failed to keep the resident's head elevated while tube feeding formula infused and provided care with the resident laying flat while tube feeding formula infused. The sample size was 24. The census was 85. Review of the facility's Enteral Nutrition policy, revised January 2014, showed: -Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents as ordered; -Policy Interpretation and Implementation; [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a stop date of 14 days or less on an as needed (PRN) psychotropic medication (a chemical substance that changes brain function and results in an alteration in perception, mood, consciousness or behavior) for one resident (Resident #84). The sample size was 24. The census was 85. Review of the facility's Use of PRN Psychotropic Drugs policy, dated October 2017, showed: -Policy Statement: Resident's drug regiment will be free from unnecessary drugs, including unnecessary psychotropic drugs; -PRN orders for psychotropic drugs are limited to 14 days, except as provided if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. He or she should document their rationale in the resident's medical record and indicate the duration for the PRN order; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that in accordance with accepted professional standards and practices, medical records are maintained that are complete and accurately documented for two residents (Residents #84 and #59). The sample was 24. The census was 85. The facility did not provide a policy for transcribing physician's orders, as requested. 1. Review of Resident #84's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/23/23, showed: -Should brief interview for mental status be conducted? No (resident rarely/never understood); -Diagnoses included: anemia (low red cell count), high blood pressure, diabetes, and dementia; -Received hospice care; -Pain frequency: occasionally. Review of the physician order sheet, in use at the time of survey, showed: -An order for: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was admitted with a Foley (brand name) catheter (a hollow tube inserted into the bladder, used to drain urine from the body) for diagnosed bladder disease received catheter care per standards of practice. The facility did not document catheter output. The resident experienced a change in condition, was sent to the hospital, where hospital staff drained purulent and foul smelling urine from the resident's bladder (Resident #1). This affected one out of two residents the facility identified as using catheters. The census was 85. Review of the urinary catheter care policy, undated, showed: -Purpose: to prevent catheter associated urinary tract infections (UTI); -General guidelines: -Input/output: observe the resident's urine level for noticeable increases or decreased. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents could safely administer their own medications for three of three residents observed with medications or treatments in their room or left at their side (Residents #34, #10 and #308). The census was 81. Review of the facility's Self-Administration policy, revised December 2016, showed: -Policy Statement: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; -Policy Interpretation and Implementation: -As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two residents (Residents #11 and #6). The facility failed to develop resident care policies for restorative services, based on professional standards of practice, including who may provide specific treatments. The facility identified 23 residents as having contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The sample was 19. The census was 81. 1. Review of the Department of Health and Senior Services, Centers for Medicare and Medicaid Services Resident Census and Condition of Residents form CMA-672, completed by the facility staff and dated 5/17/21, showed: -Mobility: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there would be a correct emergency response for one resident (Resident #29), to comply with an order for do not resuscitate (DNR, instructions to health care providers not to do cardiopulmonary resuscitation (CPR) if the heart and respirations stop) due to having two active and opposing code statuses, DNR and full code. The sample was 19. The census was 81. Review of the facility's Do Not Resuscitate Order policy, dated February 2014, showed our facility will not use CPR and related emergency measures to maintain life functions on a resident when there is a DNR order in effect. Review of Resident #29's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 11 out of a possible score of 15. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's representative (Resident #43) regarding a change in condition, which required placing the resident on suicide watch. The sample size was 19. The census was 81. Review of the facility's Change in a Resident's Condition or Status policy, revised November 2019, showed the following; -Policy Statement: -Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (examples given, changes in level of care, billing/payments, residents rights, etc.); -Policy Interpretations and Implementations: -The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or on-call physician when there has been: -A significant change in the resident's physical/emotional/mental condition; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to respect residents' right to personal privacy during personal care for two of six residents observed during personal care (Residents #207 and #448). Staff left one resident's genitals exposed to the roommate during care when they failed to pull the privacy curtain completely around the bed and exposed a resident's chest to an open window as a car was observed to pull into the facility parking lot. The sample was 19. Census was 81. Review of the facility's untitled and undated policy, provided by the facility as the perineal care (cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) policy, showed: -Purpose: To provided cleanliness and comfort to the resident, aid in the prevention of skin irritations, infection and to observe the resident's skin condition; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents regarding wounds, transfer status, Activities of Daily Living (ADLs), incontinence, colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) care, emergency code status, oxygen use, weight loss, dietary needs, hospice services and falls for 11 residents (Residents #100 #101, #207, #348 , #349, #27, #39, #10, #249, #400 and #405). The sample was 19. The census was 81. Review of the facility's Care Plans, Comprehensive Person-Centered policy, revised on 12/2016, showed: -Policy statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided according to acceptable standards of clinical practice. The facility failed to ensure treatment orders were transcribed correctly and followed as ordered for one resident (Resident #27). Staff also failed to follow physician orders for physician follow up, diet orders and application of heel protectors (Residents #200, #250 and #100). In addition, facility staff failed to accurately assess the access site for one resident (Resident #250), clarify diet orders and obtain an admission weight (Residents #249 and #251). The sample was 19 and the census was 81. 1. Review of Resident #27's most recent quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/9/20, showed: -Cognitively intact; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation. This affected three of three reviewed closed records (Residents #1, #9 and #398). The sample was 19. The census was 81. Review of the facility's Transfer and Discharge Policy dated revised November 2019, showed no mention of discharge summaries, recapitulation of the resident's stay, final summary of the resident's status and reconciliation of pre- and post-discharge medications. 1. Review of Resident #1's closed record, showed the following: -admitted on [DATE], and readmitted on [DATE]; -discharged to hospital emergency room on 3/10/21; -Diagnoses included Bipolar disorder, epilepsy and depression. Review of the resident's nursing note dated 3/10/21, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and monitor and reassess for further decline for two residents (Residents #400 and #401) that were experiencing a significant change in condition out of 19 sampled residents. The census was 81. Review of the facility's Change in Resident's Condition or Status Policy, revised [DATE], showed: -Policy statement: -- Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); - Policy Interpretation and Implementation; --The nurse will notify the resident's Attending Physician or physician on call when there has been a: --significant change in the resident's physical/emotional/mental condition; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 29 opportunities observed, four errors occurred, resulting in a 13.79% error rate (Resident #301). The sample was 19. The census was 81. Review of the facility's Administering Medications through an Enteral Tube policy, revised on 12/2012, showed: -Purpose statement included: -To provide guidelines for the safe administration of medications through enteral tube; -Preparation included: -Verifying that there is a physician order for the procedure; -Reviewing the care plan to assess for special needs; -Assembling equipment and supplies; -General guidelines included: -Following the medication administration guidelines in the policy Administering Medications; -Requesting liquid forms of medications from the pharmacy; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented, for three residents (Residents #301, #27 and #10). The sample was 19. The census was 81. 1. Review of Resident #301's medical record, showed diagnoses included stroke, gastrostomy status (having a gastric tube (g-tube) a tube inserted into the stomach through the abdominal wall to provide food, nutrition and medications), heart disease, high blood pressure, dysphagia (difficulty swallowing), seizures, and dementia. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 2/26/21, for Norco (narcotic pain medication that contains hydrocodone and acetaminophen) 5-325 milligrams (mg) every four hours as needed per g-tube. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to exercise standard infection control and prevention precautions while providing personal care to two of six residents (Residents #207 and #448). Staff did not perform appropriate hand hygiene and glove changes while providing personal care to both residents and used a soiled washcloth to wash multiple areas of the body. In addition, staff did not handle a visibly stool-soiled washcloth in a manner consistent with acceptable practices for Resident #207. The sample was 19. The census was 81. Review of an untitled and undated policy, provided by the facility as the perineal care (cleansing of the surface area between thighs, extending from the pubic bone to the tailbone) policy, showed: -Purpose: [...]