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Nursing HomeMedicaid Investigative

Stonebridge Desoto

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1550 Villas Drive, De Soto, MO 6302056 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.5/5

based on 55 Google reviews

5
4
3
2
1

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2/ 10
low Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low staffing rating (2/5 stars)
  • High staff turnover (68%)

Above average in MO · Below recommended RN staffing · Above average staffing · $8,278 in fines

Source: Medicare data

What this means for your family

While some families report positive experiences with the social work and activity teams, the recurring, serious allegations regarding hygiene and neglect are concerning. If you consider this facility, perform an unannounced visit to check the cleanliness of resident rooms and observe staff response times to call lights.

Google Reviews

Google Reviews

55 reviews on Google
Stonebridge DeSoto receives highly polarized reviews, with a significant divide between glowing praise from staff or family members and severe allegations of neglect from others. Critics consistently report issues with hygiene, including urine-stained bedding and odors, as well as understaffing that leads to delayed medication and missed meals. Conversely, supporters describe the facility as a warm, family-oriented environment with compassionate staff.

Quality Themes

Tap a score for details
Food3.0Staff5.0Clean2.0Activities8.0Meds2.0MemoryN/AComms3.0ValueN/A

Strengths

  • Friendly and compassionate staff
  • Family-oriented atmosphere
  • Helpful social work and administrative support
  • Active engagement programs

Concerns

  • Poor hygiene and sanitation (urine-stained beds, odors, mold) (mentioned by 4 reviewers)
  • Understaffing leading to neglect and delayed care (mentioned by 4 reviewers)
  • Medication management errors or delays (mentioned by 2 reviewers)
  • Missing personal belongings and clothing (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'18(4)'20(1)'22(1)'24(32)'26(3)

Distribution · 60 analyzed

5
35
4
4
3
0
2
0
1
21
23 reviews posted between Oct 14, 2024Oct 14, 2024 · 23 were 5-star

How They Respond to Reviews

7%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1Given the current staffing levels, what specific protocols do you have in place to ensure residents receive timely assistance with daily needs like hygiene and bathroom calls?
  • 2I noticed some concerns regarding facility cleanliness; could you walk me through your daily deep-cleaning schedule and how you monitor the sanitation of resident rooms and common areas?
  • 3How does your nursing team manage the medication administration process to ensure accuracy and prevent delays for residents with complex health needs?
  • 4What measures are in place to help residents keep track of their personal belongings and clothing to ensure nothing goes missing?
  • 5I see that you have a very active engagement program; could you tell me more about how these activities are tailored to residents who might have different levels of mobility or cognitive ability?
  • 6In the event of a medical emergency, what is your facility's protocol for notifying family members and coordinating care with local hospitals?

Personalized based on this facility's data


Key Review Excerpts

The amount of black mold everywhere is disgusting, they leave people in urine stained beds for days they never serve water or drinks to residents.

Family member · 2025☆☆☆☆

My dad's clothes disappeared the first day. He came home this morning in someone else's pants. None of his pants made it home and only one shirt and his jacket made it home and no socks.

Family member · 2024☆☆☆☆

Candice the social worker in particular was a godsend in terms of navigating the incredibly complicated healthcare system.

Family member · 2026★★★★★
Source: 55 Google reviews

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
1/ 5
Better Than Avg

3

measures

Worse Than Avg

11

measures

Mixed Results

3

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility36.7%
Worse than Avg
Here
36.7%
US
12.1%
MO
16.7%
Jefferson
2.8%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility34.2%
Worse than Avg
Here
34.2%
US
15.3%
MO
18.9%
Jefferson
13.7%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility32.7%
Worse than Avg
Here
32.7%
US
14.4%
MO
19.1%
Jefferson
12.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility30.2%
Worse than Avg
Here
30.2%
US
19.5%
MO
25.4%
Jefferson
18.2%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility13.3%
Better than Avg
Here
13.3%
US
15.5%
MO
23.6%
Jefferson
20.8%
⚖️

Residents who lost too much weight

↓ Lower is better
This Facility15.0%
Worse than Avg
Here
15.0%
US
5.3%
MO
5.5%
Jefferson
5.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility44.2%
Worse than Avg
Here
44.2%
US
81.8%
MO
65.9%
Jefferson
73.5%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility53.3%
Worse than Avg
Here
53.3%
US
79.8%
MO
63.5%
Jefferson
73.0%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.2%
Worse than Avg
Here
2.2%
US
1.6%
MO
2.2%
Jefferson
2.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

5deficiencies
1penalties
Well below state avg (12.0)
2 complaint-triggered
$8,278 in fines

Stonebridge DeSoto has a concerning pattern of recurring deficiencies across multiple care areas, with families filing complaints that triggered inspections. The facility repeatedly struggles with infection control, food safety, medication management, and care planning across surveys from 2022-2025. While the facility corrects issues when cited, the same problems resurface, suggesting ongoing systemic challenges with maintaining consistent standards of care and safety.

Jul 24, 2025Complaint
1
0689Actual harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Mar 13, 2025Routine
8
0321Potential for harm · Widespread

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0222Potential for harm · WidespreadCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0781Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

0920Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0812Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0577Minimal · WidespreadCorrected

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Feb 9, 2024Routine
17
0351Potential for harm · Widespread

Smoke Deficiencies

Install an approved automatic sprinkler system.

0281Potential for harm · WidespreadCorrected

Egress Deficiencies

Install proper backup exit lighting.

0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0868Potential for harm · IsolatedCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0882Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

0574Minimal · WidespreadCorrected

Resident Rights Deficiencies

The resident has the right to receive notices in a format and a language he or she understands.

Sep 20, 2023Complaint
1
0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Aug 5, 2022Routine
8
0781Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

0911Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

0920Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Federal Penalties

Fine

Jul 24, 2025

$6,368

Ownership & Operations

Who Operates This Facility

Owner / Operator

Stonebridge Desoto

Organization Type

for profit

Chain Affiliation

Chain Name

Stonebridge Senior Living

Chain Size

12 facilities nationwide

Chain avg rating: 2.7/5 · Rank 5 of 12

Ownership & Management

Owners

Lierman, Mark

Owner

100%

Key personnel

Lierman, MarkOfficer / DirectorMiller, BethOfficer / DirectorBridge Rehabilitation INCManagerBusey CorporationManagerEldercare Management Services INCManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 2 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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