Stonebridge Lake Ozark
Inspection Findings
F-Tag F0658
F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
dated [DATE REDACTED], showed staff assessed the resident as follows: -Severe cognitive impairment;-At risk of developing pressure ulcers;-Received application of ointments/medications other than to feet;-Used pressure reducing device for bed and chair. Review of the resident's weekly skin assessment, dated 10/17/25, showed staff assessed the resident with a stage two pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) to his/her right buttock. Documentation showed a treatment order received from the physician. The record did not contain documentation of a full wound assessment to include measurements or presence of exudate. Review of the resident's EMR, dated 10/18/25 through 10/30/25, showed the record did not contain documentation staff completed a skin assessment. Review of the resident's EMR, dated 11/01/25 through 11/21/25, showed the record did not contain documentation staff completed a skin assessment from 11/01/25 to 11/10/25 and from 11/12/25 to 11/21/25. During an interview on 11/21/25 at 3:27 P.M., RN A said the nurse should have documented a full assessment of the wound on 10/17/25, and the charge nurses should have completed a weekly skin assessment to monitor the wound and any other new skin concerns. 4. During an interview on 11/21/25 at 2:58 P.M., the administrator said the nurses are responsible to complete treatments as ordered by the physician and document on the TAR once completed, so if there are missing signatures on the TAR, the treatment probably wasn't done. He/She said the nurses are expected to complete a skin assessment on each resident weekly as prompted by the facility's EMR system and document a full assessment of any skin concern/wound. The administrator said he/she is aware skin assessments are not being completed as expected and will work with the newly hired Director of Nursing (DON) to address. During an interview on 11/21/25 at 3:27 P.M., RN A said he/she is the acting DON since the DON left about a month ago. RN A said the nurses are responsible to complete skin assessments weekly for each resident as prompted by the facility's EMR system. RN A said if the nurse assessed a resident with a new skin concern/open area, the nurse is expected to document the location, measurements, stage the wound (if comfortable staging), or ask the DON/assistant DON for help. RN A said he/she had been trying to audit for skin assessments and wound documentation, but it has been difficult to keep up with the increased workload. During an interview
on 11/21/25 at 3:59 P.M., RN B said the nurses are responsible to complete a skin assessment for each resident on admission, and then weekly as prompted by the facility's EMR system. RN B said the skin assessment should include the location of any identified skin concern/wound, measurements, stage and drainage (if applicable), or a general description of the area. He/She said the nurses are also responsible to complete treatments as directed by the physician and document on the TAR after administered. He/She said if there is missing documentation/signature on the TAR, the treatment likely was not administered, and
the nurse is expected to document a progress note with a reason for not administering a scheduled treatment. Complaint# 2657875
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STONEBRIDGE LAKE OZARK in OSAGE BEACH, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OSAGE BEACH, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from STONEBRIDGE LAKE OZARK or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.