Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonebridge Florissant during CMS and state inspections, most recent first.
A facility failed to ensure residents had access to mail delivered on Saturdays. Five alert and oriented residents reported that mail was no longer delivered on weekends, was held in the office until Monday, and packages could not be accessed until then. The Activity Director initially said mail was delivered on Saturdays, then clarified that the post office had stopped weekend delivery because the office was closed and packages could not be given to staff. The Administrator stated he expected residents to receive mail on Saturdays.
RN coverage was not maintained for at least 8 consecutive hours a day, 7 days a week. PBJ review showed multiple weekend days with no RN hours, and the Administrator stated there was no documentation or time sheets showing an RN was in the facility on those days. The Administrator also stated he expected RN coverage to be present at least 8 consecutive hours daily.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
Late TPL Forms for Deceased Residents’ Trust Fund Balances: The facility failed to complete TPL forms within the required timeframe for two residents who expired and had money in their resident trust fund accounts. One resident had a balance of $453.14 and the other had $3,547.24, and both TPL submissions were late. The BOM said she believed the forms were due within 60 days and sent them late, while the Administrator said he expected them to be sent within the required time frame.
Failure to provide bed-hold notice at hospital transfer for two residents. The facility’s policy required written bed-hold information to be given upon admission and before hospitalization or therapeutic leave, or within 24 hours for emergency transfers. Records showed two residents were sent to the hospital and later returned, but there was no documentation that the notice was provided to the resident or representative. The DON and Administrator stated the notice was expected to be sent with the resident and/or communicated to the representative.
Failure to complete neuro checks after an unwitnessed fall: A resident with confusion and multiple diagnoses, including anoxic brain injury, stroke history, seizure disorder, and ESRD, became combative, refused initial VS, and had an unwitnessed fall after trying to get out of a chair and again near the bathroom. The record showed no documentation that neuro checks were started, despite facility policy requiring neurological assessments after unwitnessed falls and staff stating the checks should begin right away.
A resident with severe cognitive and communication impairment developed a right ankle wound and later had additional pressure injuries identified after a hospital stay. Staff did not consistently document weekly wound assessments with measurements, wound-bed description, or staging, and the TAR showed repeated blank entries for ordered wound care and heel protectors. The resident’s wound was also not consistently tracked on the wound report, and the facility later acknowledged that staff were responsible for documenting skin issues, wound measurements, and completion of ordered treatments.
A resident who was totally dependent for care and had significant medical conditions fell from bed after a CNA left them unattended on their side on a low air loss mattress. The CNA did not immediately report the fall, delaying assessment and notification to the nurse, PCP, responsible party, and IDT, contrary to facility policy. The resident later reported neck pain and was diagnosed with a head injury at the hospital.
A facility failed to implement timely interventions to prevent falls, resulting in a resident's injury. The facility did not complete required post-fall assessments and documentation for several residents, nor did it update care plans and kardexes with necessary interventions. Staff were unsure of fall prevention measures, contributing to inadequate supervision and increased fall risk.
Delayed Saturday Mail Delivery
Penalty
Summary
The facility failed to ensure residents had reasonable access to mail delivered on Saturday and privacy in their use of communication methods. During a group interview, five alert and oriented residents stated that mail was no longer delivered on Saturdays and was instead placed in the office, which was closed on weekends, and then distributed on Monday. One resident reported that this was frustrating because packages often arrived and could not be accessed until Monday. During an interview, the Activity Director initially stated that mail was delivered on Saturdays and distributed as it arrived, but later clarified that the post office had stopped delivering mail on Saturdays because the office was closed and packages could not be given to staff members. The Activity Director stated that someone from activities was at the facility on the weekend, and the Administrator stated he expected mail to be delivered to residents on Saturdays.
RN Coverage Not Maintained 7 Days a Week
Penalty
Summary
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, and the facility’s Daily Census dated 8/17/25 showed 109 available beds and 61.5% occupancy. Review of the facility’s payroll-based journal (PBJ) report showed no RN hours on Saturday, 1/11/25; Sunday, 1/12/25; Saturday, 1/25/25; and 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 an RN was in the facility 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.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Late TPL Forms for Deceased Residents’ Trust Fund Balances
Penalty
Summary
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death was not completed as required when the facility failed to ensure third party liability (TPL) forms were completed within 30 days for residents who expired and had money in their accounts. This affected two of three sampled residents who expired and had resident trust fund balances, Resident #74 and Resident #75. Resident #74 expired with an ending balance of $453.14, and the TPL was submitted late. Resident #75 expired with an ending balance of $3,547.24, and the TPL was also submitted late. The facility’s Resident Trust Fund Account Policy and Procedure stated that upon the death of a resident with a balance in the Resident Trust Fund, the facility would complete a form and submit it to the Department of Social Services, Missouri Healthnet Division, within 30 days of the resident’s death. During interview, the BOM stated TPL notifications should be sent within 60 days and that she was busy and sent them late, while the Administrator stated he expected TPL notifications to be sent within the required time frame.
Failure to Provide Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written information to the resident and/or the resident’s representative about the bed-hold policy at the time of transfer to the hospital for two sampled residents. The facility’s Bed Hold policy stated that residents must be informed upon admission and prior to hospitalization or therapeutic leave, and that for emergency transfers the information must be provided within 24 hours. Review of the records showed that Resident #68 was discharged to the hospital on 8/7/25 and returned on 8/12/25, and Resident #33 was discharged to the hospital on 8/10/25 and returned on 8/13/25, with no documentation that a bed-hold notice was provided to either the resident or the resident’s representative. During interview, the DON stated that the bed-hold notice should be sent with the resident or provided to the resident’s representative upon discharge. The Administrator also stated that the notice was expected to be sent with the resident and/or communicated with the resident’s representative upon discharge to the hospital with an anticipated return to the facility. The record review and interviews showed no documentation indicating that the required bed-hold information was provided for these two residents.
Failure to Complete Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure care was provided consistent with professional standards when staff did not complete neurological checks after an unwitnessed fall for one resident. The facility’s fall policy required staff to evaluate and document falls, and the neurological assessment policy stated neurological assessments were indicated following an unwitnessed fall. The post-fall monitoring form also stated that an unwitnessed fall required neurological checks, with assessments to begin immediately and continue at specified intervals for 72 hours. Resident #74 was alert with confusion and had diagnoses including diabetes, anoxic brain injury, polysubstance abuse, history of stroke, seizure disorder, high cholesterol, high blood pressure, and chronic end stage renal failure. The resident’s care plan documented multiple falls and a history of falling. A progress note stated the resident became combative, repeatedly tried to get out of a chair without assistance, refused initial vital signs, and then had an unwitnessed fall after walking down the hall. The note also stated the resident fell again by the central bathroom and was later sitting at the nurse’s station. The record showed no documentation that neurological checks were started after the unwitnessed fall. Staff interviews indicated that after an unwitnessed fall, the resident should be assessed, neuro checks should begin right away, and the physician and family should be notified. Staff also stated that if the resident refused vital signs or other assessment elements, they should re-direct the resident, try again later, document the refusal, and notify the physician. The DON stated neurological checks should be initiated and completed during unwitnessed falls, but the resident’s record did not show that this occurred.
Incomplete wound assessment and missed treatment documentation
Penalty
Summary
Facility staff failed to provide wound care consistent with professional standards for one resident with significant cognitive and communication impairments, Down's Syndrome, non-Alzheimer's dementia, and non-traumatic brain dysfunction. The resident required total care for all ADLs, was incontinent of bowel and bladder, and was identified as at risk for pressure ulcers. The care plan included weekly skin assessments and monitoring for skin breakdown, and the resident developed an open area on the right lateral ankle that was first documented as a non-pressure injury after staff believed the area had been rubbed or hit on the wheelchair foot pedal. The wound documentation was incomplete on multiple occasions. The weekly skin assessments for the right lateral foot/ankle did not include measurements, wound bed description, or staging, even though the facility policy required a full assessment including location, stage, length, width, depth, exudate, and necrotic tissue. The resident’s wound was not listed on the wound report for several weeks, and progress notes repeatedly stated that the skin issue had not been evaluated. The treatment administration record also showed blank documentation for ordered wound care and heel protector use on numerous opportunities. After the resident returned from the hospital, records showed additional pressure injuries, including a left heel pressure injury and a right ankle/malleolus pressure injury. The hospital discharge instructions included wound care for the right ankle and left heel, but the facility’s treatment record did not reflect the left heel order before a later skin prep order was entered. Facility leadership acknowledged that the floor nurse was responsible for weekly skin assessments and documenting wound measurements and descriptions, that the wound doctor staged wounds, and that if treatment was not documented it meant it was not done. The DON and ADON also stated that staff were expected to identify skin issues during assessments, document them in the medical record, and follow physician orders and facility policy.
Failure to Prevent Accident and Ensure Timely Reporting After Resident Fall
Penalty
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) left a resident unattended and positioned on their side on a low air loss mattress, resulting in the resident falling out of bed onto a fall mat. The CNA had been providing incontinence care, rolled the resident to their side, and then left the room to care for other residents. Upon returning, the CNA found the resident on the floor. The bed was not in the lowest position at the time of the incident. The resident was totally dependent on staff for all activities of daily living, had quadriplegia, a traumatic brain injury, and a seizure disorder, and was cognitively intact and able to communicate what had happened. The CNA did not immediately report the fall to the charge nurse or any other staff member. Instead, the CNA checked the resident for injuries, used a Hoyer lift to return the resident to bed without assistance, and only later mentioned the incident, with uncertainty about whom it was reported to and when. The lack of immediate notification meant that the resident was not promptly assessed by a nurse for injuries, and the Primary Care Physician (PCP), responsible party, and Interdisciplinary Team (IDT) were not notified in a timely manner as required by facility policy. Facility policy required that all accidents or incidents be promptly investigated and reported, with the nurse supervisor or charge nurse completing an incident report and notifying appropriate parties within 24 hours. In this case, the policy was not followed, as the fall was not immediately reported, and the required assessments and notifications were delayed. The resident later complained of neck pain and was eventually sent to the hospital for evaluation, where a head injury was diagnosed. Interviews confirmed that the CNA was unaware of the requirement to provide care in pairs for this resident and did not know to report falls immediately.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement timely and appropriate interventions to prevent potential falls and injury for a resident who had a fall mat only on one side of the bed. This resident fell from the side of the bed that did not have a fall mat, resulting in injury. The facility did not adequately assess resident falls by failing to complete post-fall 72-hour monitoring reports, including neurological checks, for several residents. Additionally, the facility did not complete post-fall initial clinical assessments, skin assessments, or incident follow-up documentation for multiple residents. The facility's policies on managing falls and fall risk were not followed, as evidenced by the lack of documentation and updates to care plans and kardexes with interventions for fall prevention. The facility's fall documentation policy requires a full body assessment, 72-hour follow-up, and updated fall risk assessments after each fall, which were not completed for the residents involved. The facility also failed to notify physicians and resident representatives in a timely manner and did not update care plans with necessary interventions. Observations and interviews revealed that staff were unsure of the interventions in place for residents and did not consistently ensure that fall mats were correctly positioned. The facility's failure to provide adequate supervision and implement necessary interventions contributed to the residents' falls and injuries. The lack of proper documentation and communication further exacerbated the issue, as staff were not fully informed of the residents' fall risks and necessary precautions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 921 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Florissant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pillars Of North County Health & Rehab Center, The | 2.3 mi | ★★★★★ | 2 | 0 |
| Hidden Lake Health Care Center | 2.5 mi | ★★★★★ | 2 | 0 |
| Lakeview Post Acute | 2.8 mi | ★★★★★ | 1 | 0 |
| Delmar Gardens North | 2.8 mi | ★★★★★ | 17 | 0 |
| Atrium Place Health And Rehabilitation | 2.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Stonebridge Florissant.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.