Stonebridge Maryland Heights: Insulin Crisis Unreported - MO
The next morning at 3:20 a.m., a registered nurse found the same resident face down on the floor, barely breathing, foaming at the mouth, unresponsive. CPR was started. When paramedics arrived, the blood sugar was 27. They treated it on the way to the hospital. The emergency room record described the original EMS call as being for cardiac arrest.
The hospital diagnosed the resident with hypoglycemia.
This is what inspectors documented at Stonebridge Maryland Heights following a November 2025 complaint inspection.
The resident was on two diabetes medications, including Lantus, a long-acting insulin taken once daily. A blood sugar below 54 is considered severe hypoglycemia, a condition that can lead to unconsciousness and requires immediate intervention. The resident's reading of 40 that first morning cleared that threshold.
LPN A, the nurse who treated the resident that morning, told inspectors she had found the resident not responding and checked the blood sugar. She gave the glucagon, rechecked it, and the numbers came back to normal range. She made sure the resident got up and ate breakfast because, she said, she knew glucagon only lasts for a little while and the resident needed food to keep the blood sugar from dropping again. She believed she had called the physician to get the order for glucagon, but she could not say for sure. She believed she had written the change of condition on the shift change report.
She did not call the doctor's office. The physician's representative confirmed that to inspectors directly.
Physician Representative E said no one from the facility reached out to the doctor's office that day for any reason related to this resident. The facility did not notify the physician's staff of the resident's change in condition until 3:51 a.m. the following morning, after the resident had already been found on the floor and EMS had been called.
The physician, identified as Physician B, told inspectors what would have happened if someone had called. He would have held the Lantus for a day or two. He would have held the resident's oral diabetes medications as well. He would have increased blood sugar monitoring from once a day to twice a day for the next several days. None of that happened, because no one called.
The registered nurse who found the resident on the floor the following morning told inspectors she had not been made aware the resident had experienced a blood sugar of 40 the previous morning. She was working without that information when she started CPR.
A family member told inspectors that when EMS arrived at the facility, they had to perform CPR and resuscitated the resident. The blood sugar at that point was 27.
The Director of Nursing, when interviewed, said she would expect staff to follow the facility's policies and protocols.
The inspection was classified as causing minimal harm or potential for actual harm, affecting a few residents. That classification reflects the regulatory framework's language, not the family member's account of watching emergency responders perform CPR on their relative in the middle of the night, or the physician's account of the straightforward interventions that a single phone call would have allowed him to make.
LPN A knew enough about glucagon to make the resident eat breakfast. She knew the medication's effect was temporary. She understood the blood sugar could fall again. What she did not do was pick up the phone and tell the doctor that her patient had been unresponsive that morning, that the blood sugar had hit 40, and that the resident was on a long-acting insulin that would keep working through the night.
The resident was hospitalized. The record lists the diagnosis as hypoglycemia.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebridge Maryland Heights from 2025-11-14 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: June 22, 2026 · Our methodology
STONEBRIDGE MARYLAND HEIGHTS in MARYLAND HEIGHTS, MO was cited for violations during a health inspection on November 14, 2025.
The next morning at 3:20 a.m., a registered nurse found the same resident face down on the floor, barely breathing, foaming at the mouth, unresponsive.
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.