Stonebridge Adams Street
STONEBRIDGE ADAMS STREET in JEFFERSON CITY, MO — inspection on August 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and received oxygen therapy.
Review of the resident's care plan, revised 07/10/25, showed staff documented the resident should wear oxygen at two LPM continuously via nasal cannula, and to change oxygen tubing and water cannister weekly.
Review of the resident's POS, dated 08/22/25, showed physician orders as followed: -Oxygen two LPM via nasal cannula for oxygen saturation below 90% or shortness of breath every shift;-Change oxygen tubing/nebulizer mask and tubing every Sunday night shift for prevention of infection;-Ipratropium-Albuterol Inhalation Solution 0.5-2.5, three mg/three ml vial, inhale orally every six hours for productive cough.
Review of the resident's TAR, dated 08/01/25 through 08/22/25, showed staff were directed to change oxygen tubing/nebulizer mask and tubing every Sunday night shift for prevention of infection.
Observation on 08/22/25 at 9:32 A.M., showed the resident wore his/her oxygen via nasal cannula.
Observation showed the oxygen tubing undated, and the humidifier bottle, dated 07/29/25.
Observation showed a nebulizer mask on the floor, unbagged, and the tube dated 07/29/25.
During an interview on 08/22/25 at 9:32 A.M., the resident said he/she wears oxygen all the time, and staff administers a breathing treatment to him/her a few times per day. 6.
Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and received oxygen therapy.
Review of the resident's care plan, revised 06/12/25, showed staff were directed the resident to wear oxygen at all times.
Review of the resident's POS, dated 08/22/25, showed an order to change oxygen tubing and humidifier weekly on Sunday night shift for infection control.
The POS did not contain an order for oxygen.
Review of the resident's TAR, dated 08/01/25 through 08/22/25, showed staff were directed to change oxygen tubing and humidifier weekly every Sunday on night shift for infection control.
Observation on 08/22/25 at 8:40 A.M., showed the resident wore his/her oxygen.
Observation showed the nasal canula undated.
Observation on 08/22/25 at 11:22 A.M., showed the oxygen concentrator next to the resident's bed and the humidifier bottle undated.
During an interview on 08/22/25 at 2:26 P.M., the Director of Nursing (DON) said he/she did not know why the resident did not have an order for oxygen therapy on his/her POS.
The DON said the nurses are responsible to enter orders for oxygen therapy on the resident's POS and Treatment Administration Record (TAR), and he/she ensures that the orders are entered. 7.
During an interview on 08/22/25 at 1:34 P.M., Licensed Practical Nurse (LPN) A said the nurses are responsible to change residents' oxygen tubing and nebulizer mask and tubing. He/She said the schedule would be documented on the resident's POS and TAR.
During an interview on 08/22/25 at 2:26 P.M., the DON said the night shift nurse is responsible to change oxygen tubing, humidifier bottles, and nebulizer masks/tubing on Sundays for all residents with oxygen therapy, and date the tubing when changed.
The DON said he/she is responsible to ensure the oxygen and nebulizer masks, and tubing's are being changed weekly, but he/she had not had a chance to audit.
During an interview on 08/22/25 at 3:00 P.M., the administrator said the nurses are responsible to document the order for oxygen therapy on the POS and TAR on admission or when received, and the DON to ensure the orders have been entered.
The administrator said he/she did not know why the oxygen tubing, humidifier bottles and nebulizer masks and tubing's are not being changed weekly, but they should be changed by the charge nurse on Sunday nights, and the DON should ensure they are being changed.
Complaint# 2587511
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Adams Street
1024 Adams Street Jefferson City, MO 65101
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited STONEBRIDGE ADAMS STREET in JEFFERSON CITY, MO for a deficiency under regulatory tag F-F0804 during a complaint investigation conducted on 2025-08-22.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of STONEBRIDGE ADAMS STREET.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-16.