Stonebridge Adams Street: Oxygen Safety Failures - MO
The scene at Stonebridge Adams Street revealed a pattern of neglected oxygen equipment maintenance that put vulnerable residents at risk of infection. Multiple residents requiring continuous oxygen therapy were using equipment that hadn't been changed in weeks, despite physician orders requiring weekly replacement.
Resident #3, who has severe cognitive impairment and wears oxygen continuously, had oxygen tubing with no date marking when inspectors observed at 9:32 AM. The humidifier bottle was dated July 29 — 24 days earlier. The resident told inspectors he wears oxygen all the time and receives breathing treatments several times daily.
The resident's physician had ordered oxygen tubing and nebulizer equipment changes every Sunday night shift "for prevention of infection." Staff were specifically directed to change the equipment weekly on the Treatment Administration Record dated August 1 through August 22.
Nobody had changed it.
Resident #4 presented an even more troubling case. The resident, also assessed with severe cognitive impairment, was supposed to wear oxygen at all times according to care plan revisions from June 12. But when inspectors checked the Physician Order Sheet on August 22, they found no oxygen order at all.
The Director of Nursing admitted during a 2:26 PM interview that she didn't know why the resident lacked an oxygen therapy order. She said nurses are responsible for entering oxygen orders on both the Physician Order Sheet and Treatment Administration Record, and she ensures orders are entered.
The resident's oxygen concentrator sat next to the bed with an undated humidifier bottle. The nasal cannula had no date marking either.
When inspectors observed at 8:40 AM, the resident was wearing oxygen despite having no written physician order authorizing the treatment.
Licensed Practical Nurse A explained during a 1:34 PM interview that nurses handle changing residents' oxygen tubing and nebulizer equipment according to schedules documented on physician orders and treatment records. The responsibility was clear. The execution was not.
The Director of Nursing told inspectors the night shift nurse should change oxygen tubing, humidifier bottles, and nebulizer equipment on Sundays for all residents receiving oxygen therapy. She said nurses should date the tubing when changed.
She acknowledged responsibility for ensuring weekly equipment changes but admitted she "had not had a chance to audit" whether staff were following the protocol.
The administrator confirmed during a 3:00 PM interview that nurses must document oxygen therapy orders and the Director of Nursing must ensure proper documentation. He said he didn't know why oxygen equipment wasn't being changed weekly, but acknowledged the charge nurse should handle changes on Sunday nights with Director of Nursing oversight.
The violations affected residents with severe cognitive impairment who depend entirely on staff for proper medical equipment maintenance. Both residents requiring oxygen therapy had conditions that made them particularly vulnerable to respiratory infections that contaminated equipment could cause.
Federal regulations require nursing homes to provide treatment and care according to physician orders. The facility's failure to maintain clean oxygen equipment and properly document orders violated basic infection control standards designed to protect residents from preventable harm.
The inspection occurred in response to a complaint filed as case number 2587511. Inspectors classified the violations as causing minimal harm or potential for actual harm to some residents.
Stonebridge Adams Street operates at 1024 Adams Street in Jefferson City. The facility's oxygen equipment maintenance failures represent systemic breakdowns in both clinical care and administrative oversight that left cognitively impaired residents breathing through contaminated tubing for weeks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebridge Adams Street 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: June 20, 2026 · Our methodology
STONEBRIDGE ADAMS STREET in JEFFERSON CITY, MO was cited for violations during a health inspection on August 22, 2025.
The scene at Stonebridge Adams Street revealed a pattern of neglected oxygen equipment maintenance that put vulnerable residents at risk of infection.
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.