Stonebridge Lake Ozark
STONEBRIDGE LAKE OZARK in OSAGE BEACH, MO — inspection on November 21, 2025.
Found 1 citation. 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 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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