Stonebridge Maryland Heights

In the surveyor’s words

From the most serious findings on record at Stonebridge Maryland Heights, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 13, 2023

  Based on interview and record review, the facility failed to provide adequate supervision to one of three sampled residents (Resident #4). Resident #4 had a diagnosis of dementia and a history of exit seeking and attempting to leave the premises without necessary supervision. On 4/9/23, Resident #4 left the facility unsupervised when Floor Technician A opened the locked door and let the resident out of the secured unit because he/she thought the resident was a visitor. Floor Technician A did not follow facility policy and notify staff on the unit or the Director of Nursing (DON) the resident had left and did not do a thorough search for the resident. Facility staff failed to adequately monitor the whereabouts of the resident. […]

• Immediate jeopardy, isolatedF689Jan 11, 2023

  Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents. The facility had four manors (smaller residential settings, licensed and certified for skilled nursing care- which are physically separate from the main building) in addition to the main building. On [DATE] at around 10:15 P.M., the [NAME] Manor was left without any staff present. During that time, one resident (Resident #1), who had dementia and confusion, pulled the fire alarm in the [NAME] Manor and exited the building. Staff were not aware the fire alarm went off or that a resident had exited the building. When the fire department arrived, the resident was found outside, on the ground, in a pile of snow. […]

• Actual harm, isolatedF745Feb 5, 2025

  Based on observation, interview, and record review, the facility failed to provide counseling due to no payor source for two of six residents (Resident (R) 65 and R113) sampled for mental and psychosocial health out of a total sample of 33 residents. R65 was not provided counseling when suicidal ideations were expressed and R113 was not provided supportive services following the unexpected death of her husband who was her roommate in the facility due to being Medicaid pending. The failure to provide counseling resulted in psychosocial harm to both R65 and R113. […]

• Actual harm, isolatedF686Feb 16, 2023

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) received care consistent with professional standards to prevent and treat pressure ulcers (a localized injury to skin and/or underlying tissue as a result of pressure or friction). This resulted in a the resident's pressure ulcer to worsen and develop into a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed). The sample was three. […]

• No harm, potential for more than minimal, widespreadF755Aug 20, 2025

  Based on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation, for four out of six medication carts reviewed. This had the potential to affect all residents with orders for controlled substances. The census was 150.Review of the facility's Controlled Substances policy, revised 2016, showed:-Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (substances with a high potential for abuse and addiction but also have accepted medical use in treatments) and other controlled substances;-Policy Interpretation and Implementation:-Only authorized licensed nursing and/or… […]