Stonebridge Florissant: Respite Care Admission Failures - MO
The August 22 inspection, triggered by a complaint, focused on a single admission in late July that exposed how the facility handles respite patients, a category of short-term resident that the administrator acknowledged often arrives without documentation. What inspectors found was a chain of decisions, each one a step further from standard medical practice, that ended with an elderly patient urinating on the floor, threatening to hit a nurse, and then falling, unseen, somewhere down the hall.
The patient was in their nineties. Their medical history, documented in the facility's own progress notes, included a stroke, a seizure disorder, anoxic brain injury, diabetes, hypertension, hyperlipidemia, polysubstance abuse, and chronic end-stage renal failure. The daughter cared for them at home full-time. They arrived at the facility around 1 p.m. on July 24, ate lunch, received insulin, and were calm enough to be toileted without incident.
By 5 p.m., everything had changed.
The patient became combative and kept trying to get out of their chair without assistance. Nursing staff attempted to redirect them. It didn't work. The nurse called the family. The family's response, as recorded in the progress notes, was blunt: "What do you expect me to do?"
The nurse pressed for something practical, asking what the family did at home when the patient got like this. The family said to give the patient their Atarax. The nurse gave it. Along with trazodone.
Atarax is a brand name for hydroxyzine, an antihistamine with sedating properties sometimes used for anxiety. Trazodone is an antidepressant also prescribed for sleep. Neither is a fast-acting emergency intervention, and both carry sedation risks in elderly patients, particularly those with the kind of complex neurological and renal history this patient had. Giving both, to a patient already agitated and physically unstable, based on a phone conversation with a family member rather than a physician order, is what the inspection report centers on.
The administrator, interviewed the same day inspectors were on site, acknowledged the gap directly. If a resident is admitted for respite care, the administrator said, the family will bring in the orders or the facility will take the orders from the family. They also often bring medications from home. The nurse should call the physician to verify orders and document it.
The nurse did not call the physician. The nurse called the family.
The regional nurse, also interviewed that afternoon, offered a partial explanation. The resident was there for a very short time. Staff talked with them. The resident didn't bring any paperwork with physician orders. They brought a bag with medications in it. If the physician had changed the medications when they were eventually verified, the old order wouldn't be on the physician order sheet anyway. The nurse did an assessment when the resident was admitted, the regional nurse said, and it was documented in the progress notes.
That progress note is the only clinical record the inspection report references. It describes a nurse managing a rapidly deteriorating situation with no physician guidance, no verified orders, and a family on the phone who didn't know what to do either.
After the medications were given, the patient refused to sit down. They threatened to hit the nurse. They stood up and urinated on the floor in front of her. Then they walked down the hall and fell. Nobody saw it happen.
The progress note describes it as an unwitnessed fall. After that fall, staff redirected the patient toward a seat, but before they got there, the patient fell again, this time near the central bathroom.
The patient refused to allow vital signs to be taken initially. Staff eventually redirected them to the nurse's station. The progress note ends there, with the patient sitting at the nurse's station and a line that reads: "no further report at this time."
The inspection cited the facility under F0635, which covers the requirement that a facility complete a comprehensive assessment of each resident. The level of harm was recorded as minimal harm or potential for actual harm. Few residents were affected. On the scale of federal nursing home deficiencies, this is not the most severe category. There was no immediate jeopardy finding. No fine amount appears in the inspection documents.
But the citation captures something the harm level doesn't fully convey. This was a patient with a seizure disorder who fell twice in the same evening, in a facility that had no physician orders on file for them, no completed admission assessment, and no documented plan for managing the behavioral and neurological complexity that anyone reading their medical history would have anticipated. End-stage renal failure alone changes how drugs are processed and cleared from the body. A patient with that diagnosis receiving two sedating medications simultaneously, without a physician's involvement, is not a paperwork problem.
The administrator's own explanation of how respite admissions work at Stonebridge Florissant is its own kind of finding. Families bring the orders, or the facility takes the orders from the family. That is the system. The nurse is supposed to call the physician afterward to verify. In this case, the nurse didn't. But the underlying process, in which a family member's verbal instructions can set the medication course for a medically complex patient, was described not as an exception but as standard practice.
The regional nurse's comment that the resident was there for "a very short time" appears to explain why documentation was incomplete. The stay ran from July 24 to July 28, four days. The fall happened on the first night.
The daughter who cared for this patient at home every day, who knew their medications, who knew their behaviors, called the facility back when the nurse reached out and said she didn't know what to do. She suggested the Atarax. She was trying to help. The nurse was trying to help. Neither of them was a physician, and neither of them had the patient's medical records in front of them, because those records were never collected.
The patient sat at the nurse's station after the second fall. The progress note doesn't say whether they were injured. It doesn't say whether a physician was ever called that night. It ends with the patient sitting, and the nurse moving on.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebridge Florissant from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
STONEBRIDGE FLORISSANT in FLORISSANT, MO was cited for violations during a health inspection on August 22, 2025.
The patient was in their nineties.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.