Stonebridge Owensville: Transfer Safety Failure Harms Resident - MO
The November inspection, triggered by a complaint, resulted in a citation for actual harm under the federal standard requiring facilities to protect residents from accident hazards. The harm level is not the lowest tier on the federal scale. It means an inspector determined a resident was hurt.
The aide's account, given to inspectors on November 26, was direct: he or she did not think about the resident's safety and did not recall receiving in-service training on safe transfers, including at orientation. That is the person who performed the transfer.
Licensed Practical Nurse B, interviewed the same morning, said staff are directed to use a gait belt and the appropriate number of staff for every transfer. The resident in this case, the LPN said, was a two-person assist. The concern with skipping the gait belt, the LPN said, is a fall.
CNA C, interviewed minutes later, confirmed the same directive: use a gait belt when transferring a resident. Without one, the CNA said, the resident could fall or hurt themselves.
The Director of Nursing gave inspectors a slightly different account of the resident's care requirements. Where the LPN described a two-person assist, the Director of Nursing said the resident was a one-person assist with a gait belt. Both agreed the gait belt was required. The Director of Nursing said he or she did not think the aide used one, which is why staff had already been in-serviced on safe transfers by the time inspectors arrived.
That sequence is worth sitting with. A resident was harmed during a transfer. The facility responded by conducting training. Then inspectors came, and the aide who performed the transfer said they still didn't recall being trained on safe transfers from the start.
The Director of Nursing's statement that staff were already in-serviced before the inspection suggests the facility knew something had gone wrong before regulators showed up. The in-service happened. The aide couldn't point to it.
Gait belts are a basic piece of transfer equipment, a wide strap fastened around a resident's waist that gives staff something to hold during a move from bed to chair, chair to toilet, toilet to wheelchair. Their purpose is to keep a staff member's grip on the resident stable if the resident's legs give out or their balance shifts. Without one, a staff member grabbing for a resident mid-fall is reaching for whatever they can find, which is usually clothing, which is usually not enough.
The facility's own staff described the risk the same way, in three separate interviews, on the same afternoon. The LPN said fall. The CNA said fall or hurt themselves. The Director of Nursing said injury due to fall. The aide who skipped the belt said they didn't think about it.
What the inspection record does not contain is the resident's name, the nature of the harm, or what happened in the moments after the transfer went wrong. The report confirms actual harm occurred. It does not describe it further.
What it does describe is a facility where the person performing a transfer on a resident who required either one or two staff members and a gait belt did not use the gait belt, did not recall being told to, and told inspectors plainly that resident safety had not crossed their mind.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebridge Owensville from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 21, 2026 · Our methodology
STONEBRIDGE OWENSVILLE in OWENSVILLE, MO was cited for violations during a health inspection on November 26, 2025.
The harm level is not the lowest tier on the federal scale.
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.