Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Maryland Heights during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, insomnia, and documented wandering and exit-seeking behaviors was on an elopement care plan that included q15-minute checks, a wander guard, and 1:1 supervision overnight. During an early-morning shift, a CNA twice heard a door alarm while in a resident’s room; the first time, the CNA found the resident and another wanderer at the door and redirected them, but the second time the CNA found only the other wanderer, assumed that person had triggered the alarm, turned off the alarm, and did not check outside or verify the resident’s location. Shortly afterward, a CNA from another unit observed the cognitively impaired resident outside, fully dressed and knocking on that unit’s door, and escorted the resident back while notifying the charge nurses. The facility’s investigation determined the resident had left the unit, walked through the courtyard to another building, and remained outside unsupervised for several minutes because staff did not check the outdoor area when the alarm sounded the second time, despite the resident’s known elopement risk.
A resident with diabetes experienced two hypoglycemic episodes, including one where the resident became unresponsive and required emergency intervention. Staff administered glucagon and documented the event in the shift report but did not immediately notify the physician as required by facility policy. The physician was not informed until after the resident was hospitalized following the second episode, despite clear protocols for urgent notification after significant changes in condition.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Two residents in a facility were denied necessary counseling services due to their Medicaid pending status, resulting in psychosocial harm. One resident, with depression and anxiety, expressed suicidal ideations but did not receive counseling. Another resident, grieving the loss of her husband, expressed a desire to die and also did not receive supportive services. The facility's staff cited Medicaid status as a barrier, despite the Administrator stating services should be provided regardless of payment source.
The facility failed to properly label, date, and dispose of food items in the kitchen, risking foodborne illnesses for residents. An inspection revealed multiple unlabeled and expired items, including sauces, juices, meats, and milk. The DM acknowledged the oversight, attributing it to weekend staff, and emphasized the importance of adhering to food storage policies.
The facility failed to complete TPL forms within the required 30-day timeframe for 12 deceased residents with remaining account balances. The BOM misunderstood the regulation, believing the timeframe was 60 days, leading to delays. The Administrator was misinformed about the timeframe change, resulting in non-compliance with the facility's policy.
The facility failed to provide knives with meals for two residents, making them feel infantilized, and an LPN was observed standing while feeding a resident with cerebral palsy and seizure disorder, contrary to the DON's expectations. The Dietary Manager and Registered Dietitian acknowledged the need for knives, and the LPN was unaware of the requirement to sit while feeding.
The facility failed to involve six residents in their care planning process, as they were not invited to or aware of care plan meetings. Despite being cognitively intact and interested in participating, these residents and their families were not notified or included in the meetings, as confirmed by the MDS Coordinator.
The facility failed to provide complete Medicare Part A termination notices for three residents, leading to potential misunderstandings about appeal rights and service termination. The Advanced Beneficiary Notice of Non-coverage (ABN) forms were incomplete, lacking resident choices and cost information. Interviews revealed staff were unaware of how to properly fill out these forms.
The facility failed to provide a structured activity program for three residents, leading to unmet social and recreational needs. A resident reported dissatisfaction with the activities offered, while two others were not invited to participate in their preferred activities. The facility lacked an activity director and could not provide an activity calendar or attendance logs, indicating a deficiency in the activity program.
A facility failed to maintain a medication error rate below five percent, resulting in a 15.15% error rate. A CMT administered a four percent lidocaine patch instead of the ordered five percent, and several medications were not given as scheduled, despite being signed off as administered. The CMT cited insurance coverage issues and admitted to forgetting the medications, informing the DON of the errors. The facility's policy requires proper verification and documentation of medication administration.
The facility failed to follow its menu policies, leading to residents not receiving meals as planned and their food preferences not being honored. Observations showed discrepancies between the planned and served meals, affecting multiple residents. Some residents did not receive requested items like coffee, and others reported repetitive and unsatisfactory meals. The Dietary Manager and RD acknowledged that staff should not change menus without informing residents, yet no explanation was provided for the inconsistencies.
The facility failed to provide palatable meals, as observed in four residents who complained about unappetizing food. Issues included tough and soggy bread, dry meat, and lack of seasoning. A test tray confirmed inadequate food temperatures and missing components. The Dietary Manager could not explain these deficiencies, which increased the risk of resident dissatisfaction.
The facility failed to monitor antibiotic use for three residents as required by their antibiotic stewardship program. The Infection Preventionist confirmed that the Infection Control Log lacked necessary details such as start and end dates of antibiotics and criteria for administration. Despite acknowledging that many residents did not meet the criteria for antibiotic usage, there was no documentation of discussions with the medical director. The Corporate Nurse also could not provide documentation supporting adherence to the policy, and the infection surveillance checklists were incomplete.
A resident with chronic conditions and a high BIMS score was found with an Advair inhaler at the bedside without a self-administration assessment or order. The facility staff confirmed the absence of the required assessment, and the inhaler was subsequently removed. The facility's policy mandates an evaluation of residents' abilities for self-administration, which was not conducted in this case.
A resident was inaccurately coded as receiving dialysis in their MDS assessment, despite having no physician orders for dialysis and confirming they had never been on dialysis. The MDS Coordinator admitted to the error, citing confusion with another resident, and the DON confirmed the resident was not receiving dialysis.
A facility failed to complete a PASARR Level I screen before admitting a resident with dementia and Parkinson's disease, leading to a potential oversight in identifying necessary specialized services. Staff interviews revealed confusion about the responsibility for completing the screen, with the Social Services Director and Assistant Director of Nurses unsure of the process if the hospital did not complete it.
A resident with hemiplegia and hemiparesis following a stroke did not receive necessary range of motion treatment due to her Medicaid status being pending. Despite being cognitively intact and having a care plan indicating the need for assistance with mobility, there was no evidence of a restorative plan or therapy evaluation. The facility lacked a policy for providing services during pending financial status, contributing to the deficiency.
A facility failed to monitor and document targeted behaviors for a resident with vascular dementia receiving psychotropic medications, as required by their care plan. Despite being prescribed Seroquel and Sertraline, no behaviors were documented in the resident's records, which was confirmed by staff interviews. This lack of documentation could lead to unnecessary medication use.
A facility failed to follow infection control guidelines during wound care for a resident with pressure ulcers. The Wound Care Nurse did not wear gloves or a gown, placed the resident's heel directly on the bed without a barrier, and reused gauze on the wound. The Director of Nursing confirmed these actions were against protocol.
Resident Elopes Outside After Door Alarm Not Fully Investigated
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and oversight to prevent an elopement for one cognitively impaired resident who wandered outside unsupervised. The resident had severe cognitive impairment, diagnoses of Alzheimer’s disease, non-Alzheimer’s dementia, and insomnia, and was care planned as an elopement risk and wanderer. The care plan included every 15-minute checks due to attempts to get out of the building, monitoring when pacing to ensure the resident was not attempting to exit seek, a wander guard on the right ankle each shift, and 1:1 supervision from 7 p.m. to 7 a.m. due to attempts to exit the building. The resident’s medical record documented ongoing exit-seeking and wandering behaviors, including notes that the resident remained on frequent monitoring due to continued exit-seeking behaviors and that the wander guard was in place and functioning properly. On the night of the incident, staff documented that the resident had been exit seeking and wandering, with interviews indicating the resident began exit seeking around 4:00 a.m. and was redirected from the exit door multiple times. CNA B reported that during the early morning hours, while providing care in a resident’s room, the door alarm sounded twice. The first time, around 5:30 a.m., CNA B found the resident and another known wanderer at the door, redirected both away from the exit, and returned them to the sitting area before resuming care of other residents. Approximately 15 minutes later, around 5:45 a.m., the door alarm sounded again. CNA B reported finding only the other wandering resident at the door, assumed that resident had triggered the alarm, turned off the alarm, and did not check outside the door or verify the whereabouts of the cognitively impaired resident. Subsequently, CNA C in another housing unit observed the cognitively impaired resident outside, fully dressed, knocking on the door of that unit at approximately 6:00 a.m. CNA C recognized the resident as belonging to a different unit, escorted the resident back to the correct unit, and notified the CNAs there and the charge nurse. CNA E corroborated that the resident had been exit seeking earlier in the night and stated that the resident was calm and seated in the main area before staff began morning rounds. CNA E reported not hearing the alarm while in the shower room with another resident and only became aware the resident had been outside when CNA C returned the resident. The facility’s investigation concluded that the resident had wandered from the assigned building, walked through the courtyard to another building, and was outside unsupervised for an estimated five to ten minutes between the last sounding of the door alarm and being found at the other unit’s door. The investigation determined that although alarms functioned and sounded, staff did not check the outdoor area when the alarm activated the second time, and the DON and Administrator stated it was not appropriate for staff to ignore any alarm and that they expected staff to check outside and conduct a head count when an alarm sounded. The resident’s medical record documented that when the incident was reported to the nurse, a head-to-toe assessment and neuro checks were performed, with no injuries or changes from the resident’s previous level of functioning noted. Due to poor memory, reasoning, and understanding, the resident was unable to provide an account of what had occurred. Progress notes around the time of the incident continued to describe the resident’s wandering, exit-seeking behaviors, and the use of frequent monitoring and observation precautions. Staff interviews and the facility’s written investigation emphasized that the resident had been wandering throughout the night and that, despite being on elopement precautions and having a wander guard in place, the resident was able to leave the unit and remain outside unsupervised until discovered by staff from another unit.
Failure to Notify Physician After Significant Change in Resident Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician following significant changes in the resident's physical status, specifically after two hypoglycemic episodes. The first episode occurred when the resident was found unresponsive with a blood sugar of 40, and glucagon was administered by an LPN. The LPN did not notify the physician at that time, believing the situation was resolved after the resident's blood sugar normalized and the resident ate breakfast. Documentation of the event was limited to the shift change report, and no direct communication with the physician occurred. Later, the resident experienced a second, more severe hypoglycemic episode during the following shift, where the resident was found unresponsive, hardly breathing, and foaming at the mouth. Emergency services were called, CPR was initiated, and the resident was transported to the hospital with a blood sugar of 27. The physician was not notified of the initial hypoglycemic event or the subsequent change in condition until after the second, critical episode had occurred and the resident had already been sent to the hospital. Interviews confirmed that the physician and physician's office were not contacted regarding the resident's initial hypoglycemic episode, and the physician stated that he would have altered the resident's diabetes management had he been informed. The facility's policies required immediate physician notification for significant changes in condition, including hypoglycemic episodes, but these protocols were not followed by staff. The resident's care plan and physician orders included specific instructions for diabetes management and hypoglycemia response, which were not fully adhered to in this case.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Counseling Services Due to Medicaid Pending Status
Penalty
Summary
The facility failed to provide necessary counseling services to two residents, R65 and R113, due to their Medicaid pending status, resulting in psychosocial harm. R65, who was admitted with diagnoses including depression and anxiety disorder, expressed suicidal ideations on multiple occasions. Despite being cognitively intact and prescribed antidepressants, R65 did not receive counseling services. The facility's Social Service Designee (SSDE) acknowledged the lack of counseling, citing the pending Medicaid status as the reason. The Administrator confirmed that services should be provided regardless of payment source, but no policy was in place to address service provision during pending financial status. R113, who was also cognitively intact, experienced the unexpected death of her husband, who was her roommate in the facility. Following this traumatic event, R113 expressed a desire to die and reported that no one had provided counseling or supportive services. The SSDE admitted that R113 had not been referred for counseling due to her Medicaid status. The Assistant Director of Nursing (ADON) noted that R113 was tearful and had declined additional antidepressants, but this was not documented. The Social Services Director (SSD) was unaware of R113's statements about wanting to die, indicating a lack of communication and monitoring. The facility's failure to provide medically-related social services to R65 and R113 highlights a significant deficiency in addressing the mental and psychosocial health needs of residents. Both residents were left without appropriate interventions or referrals to mental health professionals, despite expressing severe distress and suicidal thoughts. The lack of documentation and communication among staff further exacerbated the situation, leaving the residents without the necessary support during critical times.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling, dating, and disposal of food items in the main kitchen, which could potentially lead to the spread of foodborne illnesses among residents. During an inspection, several food items were found in the kitchen's reach-in refrigerator without labels or dates, including a container of unidentified white sauce, a quart of Thick and Easy orange juice, an opened package of hot dogs, a gallon of milk, bags of mixed vegetables, hard-boiled eggs, a whole ham, sliced ham, sweet pickle relish, and lunch meat. Additionally, expired milk cartons were found in both the reach-in and walk-in refrigerators. The Dietary Manager (DM) acknowledged these issues during an interview, stating that the weekend staff was responsible for ensuring food items were labeled and not outdated. The DM expressed an expectation that all dietary staff should be aware of and adhere to the facility's food storage policy, which mandates labeling, dating, and monitoring of refrigerated food to ensure it is used by its use-by date. This oversight in food management practices posed a risk to the health and safety of 140 out of 142 residents in the facility.
Failure to Timely Complete TPL Forms for Deceased Residents
Penalty
Summary
The facility failed to complete Third Party Liability (TPL) forms within the required 30-day timeframe for residents who had expired, affecting 12 residents with remaining balances in their accounts. The facility's policy mandates that upon a resident's death, the appropriate forms must be completed and submitted to the Department of Social Services within 60 days, but the TPL forms should be completed within 30 days. However, the Business Office Manager (BOM) misunderstood the regulation, believing the timeframe for TPL completion was 60 days, leading to delays in processing these forms. The deficiency was identified through interviews and record reviews, revealing that the BOM was unaware of the correct 30-day requirement, and the Administrator was misinformed by the BOM about a supposed change to a 60-day timeframe. This misunderstanding resulted in the facility not adhering to the policy, affecting the final accounting for the deceased residents' trust funds. The residents involved had varying account balances, ranging from $0.88 to $2,018.08, which were not processed in a timely manner as per the facility's procedures.
Deficiencies in Dining Experience and Feeding Assistance
Penalty
Summary
The facility failed to uphold residents' rights to a dignified dining experience by not providing knives with meals for two residents, which made them feel infantilized. During interviews, these residents expressed dissatisfaction with the lack of knives, stating it made them feel like children. Observations confirmed that residents were only given spoons and forks, and meals were served randomly, causing some residents to wait without meals while others at the same table were served. The Dietary Manager and Registered Dietitian acknowledged that knives should be provided, and there was no reason for their absence. Additionally, the facility did not ensure proper feeding practices for a resident with cerebral palsy and seizure disorder who required assistance with eating. An LPN was observed standing while feeding this resident, contrary to the Director of Nurses' expectations that staff should sit while assisting residents with meals. The LPN was unaware of the requirement to sit, and the Director of Nurses confirmed the improper practice upon observation. The facility did not provide a policy for dining assistance, and the Administrator noted that the LPN was only helping out and should have known not to stand.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that six out of seven residents reviewed for care planning were afforded the right to participate in their care planning process. This deficiency was identified through interviews and record reviews, revealing that residents were not invited to or aware of care plan meetings. For instance, one resident, who was cognitively intact, was unaware of what a care plan meeting was and had no documentation of attending any meetings in 2024, except for one instance. The facility's administrator confirmed the lack of documentation for additional meetings. Another resident, also cognitively intact, expressed that she had not been invited to care plan conferences for several years, despite her interest in attending. The MDS Coordinator could not provide documentation of invitations or attendance for this resident. Similarly, another resident reported never being invited to a care conference, and the MDS Coordinator confirmed the absence of invitations for this resident as well. Additionally, family members of two residents reported never being invited to care plan meetings, despite being regularly present at the facility and willing to participate. The MDS Coordinator confirmed that these residents and their families had not been sent notifications or invited to care plan meetings. This lack of involvement in care planning placed residents at risk of not being aware of the goals and outcomes of their care.
Incomplete Medicare Notices for Residents
Penalty
Summary
The facility failed to issue the appropriate notice for termination of Medicare Part A benefits for three residents, which could lead to a lack of understanding of appeal rights and the termination of care against the residents' wishes. The review of the facility's policy and CMS guidelines revealed that the Advanced Beneficiary Notice of Non-coverage (ABN) forms were not filled out correctly. Specifically, the forms lacked the necessary options for residents to choose whether they wanted to continue skilled services with payment responsibility, discontinue services, or appeal for further coverage. Additionally, the forms did not include the reason why Medicare would not pay or the estimated cost of services if residents chose to pay out of pocket. For Resident 92, the Notice of Medicare Non-Coverage (NOMNC) did not specify which therapy would be discontinued after the last covered day, and the ABN form was incomplete, lacking the resident's choice and cost information. Similarly, Resident 1's NOMNC and ABN forms were incomplete, with no specific therapy discontinuation details or resident choices indicated. Resident 49, who was moderately cognitively impaired, also had incomplete forms, with the ABN lacking the necessary options and cost details, despite verbal consent from the resident's representative. Interviews with the Social Services Designee (SSDE) and the Administrator revealed a lack of knowledge and understanding regarding the completion of these forms. The SSDE admitted to not specifying which therapy would be discontinued and leaving cost information blank due to a lack of knowledge on where to obtain this information. The Administrator acknowledged the issue and stated that the SSDE is responsible for ensuring all areas of the forms are filled out completely and correctly.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of resident-preferred activities for three residents, leading to a deficiency in meeting their social and recreational needs. Resident 27, who was cognitively intact, expressed dissatisfaction with the activities offered, stating that she was only given coloring pages, which she did not enjoy. Her care plan indicated preferences for watching television and listening to music, but there was no evidence of her participation in these activities. Similarly, Resident 93, also cognitively intact, reported not being invited to any activities despite her care plan listing preferences for group activities such as bingo and trivia. The facility did not provide documentation of her participation in these activities. Resident 137, who was cognitively intact, was unaware of any activities available in the facility and expressed a desire to go outside for fresh air. Her care plan included preferences for group activities, but there was no record of her involvement. The facility's administrator acknowledged the absence of a qualified activity director since the previous director resigned, and the current activity program was being managed by CNAs and an activity assistant. However, the facility could not provide an activity calendar or attendance logs for the past six months, indicating a lack of structured activity programming.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 15.15%. This was due to five errors occurring out of 33 opportunities for error. The errors included a resident not receiving medications as ordered and receiving a medication at an incorrect strength. Specifically, a Certified Medical Technician (CMT) administered a four percent lidocaine patch to a resident's right knee, contrary to the physician's order for a five percent patch. Additionally, several medications, including Fexofenadine, Spironolactone, Artificial Tears, and Gabapentin, were not administered as scheduled during the morning medication pass, despite being signed off as given. The CMT involved stated that the insurance would not cover the five percent lidocaine patches, leading to the use of the four percent patches. The CMT also admitted to forgetting to administer the other medications and informed the Director of Nursing (DON) of the oversight. The DON acknowledged awareness of the issues but was unsure why the correct patches were not ordered and noted that the CMT was too nervous to report the medication omissions immediately. The facility's policy on administering medications requires verification of the right resident, medication, dosage, time, and method before administration, and documentation if a drug is withheld or given at a different time.
Failure to Follow Menus and Honor Resident Preferences
Penalty
Summary
The facility failed to adhere to its menu policies, resulting in residents not receiving meals as planned and their food preferences not being honored. The facility's policy required menus to be followed, provide a variety of foods, and be approved by a Registered Dietitian. However, observations revealed that the meals served did not match the planned menus. For instance, on a specific date, residents were supposed to receive spaghetti with meat sauce and a specific salad for lunch, but instead received peas and carrots, a slice of white bread, and oranges. Similarly, the dinner menu was supposed to include a beef and bean burrito, but residents were served chicken tenders and other items not listed on the menu. This inconsistency in meal service affected multiple residents, including those with specific dietary preferences and needs. Several residents expressed dissatisfaction with the meals, noting that their preferences were not considered, and they often received food they did not like or want. One resident, who was cognitively intact, reported not receiving coffee with breakfast despite repeated requests and was served pork patties, which she did not eat. Another resident complained about the lack of condiments and the repetitive nature of the meals. Interviews with the Dietary Manager and Registered Dietitian revealed that staff were not supposed to change the menu without informing residents, and there was no explanation for the discrepancies. The failure to follow the menu and honor residents' preferences placed a significant number of residents at risk of nutritional problems and dissatisfaction with their meals.
Failure to Provide Palatable Meals
Penalty
Summary
The facility failed to provide palatable meals for four residents, leading to dissatisfaction with the meals served. Residents reported that the food was unappetizing, with complaints about tough and soggy bread, dry meat, and lack of seasoning. Observations confirmed these issues, as one resident was seen licking the bread and leaving the table without finishing the meal, while another threw the sandwich off the plate and only ate a few French fries. The Dietary Manager's job description indicated responsibility for ensuring meal standards, but the manager could not explain the lack of seasoning or condiments. A test tray revealed further deficiencies, with food items served at inadequate temperatures and missing components like the dinner roll and pie. The ham was dry and difficult to chew, the carrots lacked seasoning and glaze, and the potatoes were dry. The Dietary Manager verified the temperatures, which were below acceptable levels, and acknowledged the absence of condiments, but could not provide an explanation for these oversights. This failure to meet meal standards increased the risk of residents not being satisfied with their meals.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to monitor the use of antibiotics for three residents as part of their antibiotic stewardship program. The facility's policy required the implementation of an antibiotic stewardship program, including protocols and a system to monitor antibiotic use. However, the Infection Preventionist (IP) confirmed that the facility's Infection Control Log did not contain the required start and end dates of administered antibiotics or the criteria for administration. The IP acknowledged that numerous residents did not meet the criteria for antibiotic usage and had discussed this issue with the facility medical director, but could not provide documentation of this discussion. Additionally, the Corporate Nurse was unable to provide documentation supporting adherence to the antibiotic stewardship policy for the residents in question, and the infection surveillance checklists provided were incomplete.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications before allowing medications to be left at the bedside. Resident 68, who was cognitively intact with a BIMS score of 14 out of 15, was observed with an Advair inhaler at the bedside on multiple occasions. The resident had been readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, chronic diastolic congestive heart failure, and morbid obesity. Despite the resident's cognitive status, there was no documented assessment for self-administration, nor was there an order for the medication to be kept at the bedside. The deficiency was identified when the inhaler was observed at the resident's bedside on several occasions, and the facility staff could not provide a self-administration assessment document. The LPN confirmed the absence of an assessment and stated that the inhaler was removed and returned to the medication cart after being notified by the Administrator. The Director of Nursing also confirmed that the resident had not been assessed for self-administration of the inhaler, which was against the facility's policy requiring an evaluation of the resident's mental and physical abilities for self-administration of medications.
Inaccurate MDS Coding for Dialysis
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one of the sampled residents, identified as R121. R121 was admitted with diagnoses of anemia, orthostatic hypotension, and generalized weakness. The quarterly MDS assessment indicated that R121 was receiving dialysis, which was incorrect. A review of R121's physician orders showed no orders for dialysis, and during an interview, R121 confirmed never having been on dialysis. The MDS Coordinator admitted to mistakenly coding R121 as receiving dialysis due to confusion with another resident. The Director of Nursing confirmed that R121 was not receiving dialysis.
Failure to Complete PASARR Level I Screen Prior to Admission
Penalty
Summary
The facility failed to ensure the completion of a Pre-Admission Screen and Resident Review (PASARR) Level I screen prior to the admission of a resident, identified as R112, who was reviewed for PASARR among a sample of 33 residents. R112 was admitted with diagnoses including unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, as well as Parkinson's disease without dyskinesia. The resident's electronic medical record (EMR) lacked evidence of a PASARR Level I screen and determination before admission, which is crucial for identifying necessary specialized or rehabilitative services and determining the appropriateness of the resident's placement in the facility. Interviews with facility staff revealed a misunderstanding regarding the responsibility for completing the PASARR Level I screen. The Social Services Director believed the hospital was responsible for completing the screen before admission, with a 72-hour window for the facility to complete it if not done. The Assistant Director of Nurses was unsure who should complete the screen if the hospital did not. The Administrator mentioned that a C form was done but deleted since a Level 2 was not needed, and stated that if the hospital did not complete the PASARR Level I screen, the admission person and social services should follow up. This lack of clarity and communication led to the deficiency in ensuring the PASARR Level I screen was completed for R112 prior to admission.
Failure to Provide Range of Motion Treatment Due to Pending Medicaid Status
Penalty
Summary
The facility failed to provide range of motion treatment to a resident, identified as R65, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke. Despite being cognitively intact, as indicated by a BIMS score of 15 out of 15, R65 did not receive any physical therapy, occupational therapy, or range of motion exercises as noted in the Minimum Data Set assessments. The care plan indicated that R65 required assistance with activities of daily living and mobility, with a goal to improve mobility and independence. However, there was no evidence of a restorative plan or evaluation by a therapist, which was confirmed by the Restorative Aide. R65 expressed a desire for therapy to regain strength and return home, but stated that services were not provided due to her Medicaid status being pending. The Business Office Manager acknowledged that Medicaid processing could take a long time, and the Administrator stated that services should be provided regardless of payment source, yet could not explain why R65 had not received the necessary services. Additionally, the facility lacked a policy to address the provision of services during a pending financial status, contributing to the deficiency in care for R65.
Failure to Monitor Targeted Behaviors for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to monitor targeted behaviors for a resident diagnosed with vascular dementia and hallucinations, who was receiving psychotropic medications. The resident was admitted with a diagnosis of vascular dementia and hallucinations and was prescribed Seroquel, an antipsychotic, and Sertraline, an antidepressant. The care plan for the resident included monitoring and documenting behaviors such as skin picking, agitation, hallucinations, and refusal of care. However, a review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2024 and January 2025 revealed no documentation of targeted behaviors. Interviews with facility staff, including an LPN and the Minimum Data Set Coordinator, confirmed the absence of documented behaviors in the resident's electronic medical record. The facility's policies on Behavioral Assessment, Intervention and Monitoring, and Antipsychotic Medication Use require documentation of specific target behaviors and monitoring for efficacy and adverse consequences. The lack of documentation had the potential for the resident to receive medications unnecessarily, as there was no recorded evidence of the behaviors that warranted the use of psychotropic medications.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during a wound care observation for a resident with diabetes mellitus and congestive heart failure, who had one stage four and one unstageable pressure ulcer. The resident's care plan included specific interventions for wound management, such as obtaining a culture if drainage was present and providing wound care per treatment order. However, during the wound care observation, several breaches in infection control were noted. The Wound Care Nurse (WCN) cleaned scissors and the overbed table without wearing gloves, did not wear a gown despite the resident being on Enhanced Barrier Precautions, and placed the resident's heel directly on the bed without a barrier. Additionally, the WCN used improper technique by patting the wound with a clean 4x4 gauze, folding it, and then using the same gauze to pat the wound bed again. When questioned about these practices, the WCN denied the observed breaches. The Director of Nursing confirmed that the nurse should have worn a gown, used gloves when cleaning, and used a new gauze for each patting of the wound bed, as well as a barrier for the resident's heel.
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Illustrative
What surveyors actually found near you
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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.
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Illustrative
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Nursing homes near Maryland Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkwood Skilled Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 7 | 0 |
| Nhc Healthcare, Maryland Heights | 0.8 mi | ★★★★★ | 6 | 0 |
| River Crossing Rehab And Healthcare Center | 1 mi | ★★★★★ | 0 | 0 |
| Avenir At Mark Twain | 1.1 mi | ★★★★★ | 40 | 0 |
| Ssm Health Depaul Hospital - Anna House | 1.5 mi | ★★★★★ | 1 | 0 |
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