Stonebridge Lake Ozark: Care Quality Deficiency - MO
The wound appeared in a weekly skin assessment dated October 17, 2025. A physician sent over a treatment order. But the record contained no full wound assessment, no measurements, no notation of drainage. Then the documentation stopped almost entirely.
From October 18 through October 30, there is no record of a skin assessment being completed. In November, assessments were missing from the 1st through the 10th, and again from the 12th through the 21st, the day inspectors arrived.
The administrator did not dispute what the records showed. During an interview that afternoon, he said that if signatures were missing from the treatment administration record, the treatment probably wasn't done.
The facility's director of nursing had left about a month earlier. RN A, serving as acting DON, told inspectors she had been trying to audit skin assessments and wound documentation but said the increased workload had made it difficult to keep up. She acknowledged the nurse who found the wound on October 17 should have documented a full assessment that same day, and that charge nurses should have been completing weekly checks to monitor it and catch any new skin concerns.
RN B laid out what those assessments were supposed to include: location, measurements, stage, drainage if present, or at minimum a general description of the area. If a nurse couldn't stage a wound, RN B said, they were expected to ask the DON or assistant DON for help. If a treatment was skipped, a progress note explaining why was required. None of that happened consistently here.
The administrator said he was aware the assessments weren't being completed as expected and planned to address it with the newly hired director of nursing. The resident, who was already flagged as at risk for pressure ulcers and using pressure-reducing devices for both bed and chair, had been in that condition the entire time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebridge Lake Ozark from 2025-11-21 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: August 4, 2026 · Our methodology
STONEBRIDGE LAKE OZARK in OSAGE BEACH, MO was cited for violations during a health inspection on November 21, 2025.
The wound appeared in a weekly skin assessment dated October 17, 2025.
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.