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Complaint Investigation

Stonebridge Maryland Heights

Inspection Date: August 20, 2025
Total Violations 2
Facility ID 265486
Location MARYLAND HEIGHTS, MO
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Inspection Findings

F-Tag F0658

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0658

medication had been administered. 2591516

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Stonebridge Maryland Heights

2963 Doddridge Avenue Maryland Heights, MO 63043

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0755

Pharmacy Service Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

how to do a thorough controlled substance count. He/She had never poured out a liquid controlled substance to account for the exact amount of liquid in the bottle. Sometimes the count wasn't done because only one person was available for all four buildings. 10. During an interview on 8/20/25 at 11:30 A.M., LPN D said, licensed nurses and/or CMTs should count controlled substances when they came on duty and when they went off duty. He/She tried to make sure the controlled substances were counted each day he/she came in and left work. Each building had its own narcotic account book. Each resident had an individual count sheet and then there was a sheet to document how many cards and/or bottles of controlled substances were in each building. He/She had never poured a liquid controlled substance from the bottle into a measuring cup to assure the count was accurate. He/She was aware of the missing controlled substances from [NAME]. He/She worked the morning shift the day prior to the medications going missing.

He/She counted the medications at the end of his/her shift. 11. During an interview on 8/20/25 at 2:30 P.M.,

the Administrator and DON said they were unaware staff were not always counting the controlled medications shift to shift. They were unaware staff routinely left the medication cart keys unattended in the nurse's station. They were unaware staff were not accounting for liquid medications by pouring it into a measuring cup to assure accuracy. Controlled medications should be counted shift to shift by the on-coming and off-going nurse or CMT. The documentation in the narcotics books should be complete and accurate.

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📋 Inspection Summary

STONEBRIDGE MARYLAND HEIGHTS in MARYLAND HEIGHTS, MO inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MARYLAND HEIGHTS, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from STONEBRIDGE MARYLAND HEIGHTS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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