Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonebridge Lake Ozark during CMS and state inspections, most recent first.
Staff failed to document wound treatments as ordered, did not complete full wound assessments, and missed weekly skin assessments for several residents with wounds. These deficiencies were confirmed through record review and staff interviews, revealing lapses in following physician orders and facility protocols for wound care and documentation.
A resident with severe cognitive impairment and dementia was inappropriately touched on the chest by another cognitively impaired resident. The incident was discovered by a nurse, and neither resident's care plan included interventions related to the sexual altercation. Staff interviews confirmed the event and that both residents were placed on frequent checks afterward, but no preventive measures were documented prior to the incident.
Staff did not update or revise care plans for two residents with severe cognitive impairment and behavioral issues, including wandering, exit-seeking, and inappropriate behaviors. Despite documented incidents and staff awareness, care plans lacked necessary interventions and documentation to address these behaviors, as confirmed by staff interviews and resident observations.
Facility staff failed to review and obtain physician orders for the code status of two residents, despite policies requiring completed Advance Directives and DNR orders. Interviews revealed confusion among staff about responsibilities, with RN B, SSD, and DON expressing uncertainty. The absence of documented code status orders poses a risk of inappropriate emergency interventions, such as performing CPR against residents' wishes.
The facility failed to include code status in the care plans for three residents, despite it being documented in their medical records. Interviews with staff, including a CNA, LPN, DON, and MDS Coordinator, confirmed that code status should be part of the care plans. The MDS Coordinator admitted responsibility for the oversight, which could lead to delays in care or actions against residents' wishes.
Facility staff failed to update care plans for two residents: one who began dialysis and another with a change in code status to DNR. Despite facility policy requiring immediate updates for changes in condition, the care plans were not revised. Interviews with staff, including the MDS coordinator, revealed that these updates were missed, potentially impacting resident care.
The facility failed to monitor and store controlled medications safely, as staff did not maintain control logs for medications in the destruction cabinet. Policies required counting and documenting controlled substances at shift changes, but this was not done for medications like Hydrocodone/APAP and Lorazepam. Interviews revealed staff were unaware of the medications in the cabinet, and the ADON had not checked it due to increased responsibilities. The DON and administrator confirmed the need for proper logging and counting, but the destruction cabinet was not monitored effectively.
Failure to Document and Assess Wound Care and Skin Integrity
Penalty
Summary
Facility staff failed to maintain professional standards of care by not documenting the administration of wound treatments as ordered by physicians, not completing wound assessments, and not performing weekly skin assessments for multiple residents with wounds. Specifically, for one resident, there were repeated omissions in documenting wound treatments on the Treatment Administration Record (TAR) for various wounds, including a right leg below-knee amputation, buttocks, and left heel. The records also lacked full assessments of these wounds on several occasions, despite ongoing physician orders for wound care. The facility's own policy required comprehensive wound assessments and weekly skin evaluations, which were not consistently performed or documented. Another resident, who was assessed as having severe cognitive impairment and receiving hospice care, did not have documented weekly skin assessments for multiple periods, even though the wounds were being assessed by external providers such as a wound physician and hospice nurse. However, facility nurses were still expected to complete and document these assessments, as confirmed by staff interviews. Similarly, a third resident with severe cognitive impairment and at risk for pressure ulcers had a stage two pressure ulcer identified, but the documentation did not include a full wound assessment or regular weekly skin assessments as required. Interviews with facility staff, including the acting Director of Nursing (DON) and other registered nurses, confirmed that nurses were responsible for completing and documenting wound treatments and weekly skin assessments. Staff acknowledged that missing documentation likely indicated that treatments were not administered, and that full wound assessments were not being completed as expected. The administrator and acting DON were aware of these documentation lapses and the failure to adhere to the facility's protocols for wound care and skin assessments.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
Facility staff failed to protect a resident from sexual abuse when another resident inappropriately touched the resident's chest. Documentation shows that a nurse discovered one resident's hand down another resident's shirt, making inappropriate contact. Both residents involved were assessed as having severe cognitive impairment, with one resident diagnosed with dementia and the other with a history of stroke and anxiety. The affected resident's care plan did not include interventions related to the sexual altercation, and the incident was documented in the resident's progress notes. The facility's policy states that each resident has the right to remain free from abuse, including sexual abuse, and defines such abuse as non-consensual contact of any type. Despite this, neither resident's care plan contained documentation or interventions addressing the inappropriate touching incident. Staff interviews confirmed awareness of the incident and that both residents were placed on 15-minute checks following the event, but prior to the incident, there were no specific interventions in place to prevent such occurrences.
Failure to Revise Care Plans for Residents with Behavioral Issues
Penalty
Summary
Facility staff failed to revise and implement comprehensive, person-centered care plans for two residents with behavioral issues, as required by facility policy. For one resident with severe cognitive impairment and a diagnosis of dementia, staff documented multiple incidents of wandering, exit-seeking, inappropriate entry into other residents' rooms, and physical and verbal behaviors. Despite these documented behaviors and an elopement evaluation indicating moderate risk, the resident's care plan did not include interventions or documentation addressing wandering, elopement, or behavioral symptoms, nor did it reflect actions following a resident-to-resident sexual altercation. Observations confirmed the resident's wandering behavior, and interviews with staff revealed a lack of awareness regarding specific interventions for these behaviors prior to the implementation of 15-minute checks. The MDS nurse acknowledged the omission of wandering and elopement risks from the care plan, attributing it to an oversight. Other staff, including CNAs, CMTs, LPNs, and the DON, confirmed the resident's behavioral patterns and expressed that such behaviors and incidents should have been included in the care plan, but were not. For the second resident, also with severe cognitive impairment and a history of verbal behavioral symptoms, the care plan did not address sexually inappropriate behaviors, despite staff being made aware of an incident involving inappropriate touching of another resident. The MDS nurse did not update the care plan, believing the incident was only an allegation. Both the LPN and DON stated that the care plan should have been updated to reflect the new behavior and interventions, but this was not done.
Failure to Document Code Status for Residents
Penalty
Summary
The facility staff failed to review and obtain physician orders for the code status of two residents, which is a critical aspect of honoring residents' rights to request, refuse, or discontinue treatment. The facility's policies on Advance Directives and Do Not Resuscitate (DNR) orders require that these directives be completed, signed, and easily accessible in the resident's medical records. However, for Resident #42 and Resident #159, there were no completed Advance Directive forms or physician orders for their preferred code status, despite their care plans indicating a DNR status. Interviews with staff revealed a lack of clarity and responsibility regarding the process of obtaining and documenting code status orders. Registered Nurse (RN) B and the Social Services Director (SSD) both expressed uncertainty about who was responsible for obtaining the orders, with each suggesting it was the other's responsibility. RN C admitted to forgetting to document the code status due to being busy, and the Director of Nursing (DON) acknowledged that the admitting nurse should handle this but was unsure why it was not done. The administrator confirmed that the admitting nurse should complete the paperwork and obtain a physician's order. The absence of documented code status orders for these residents poses a risk of inappropriate emergency interventions, such as performing CPR against the residents' wishes. The facility's failure to ensure that code status orders were obtained and documented reflects a breakdown in communication and adherence to established policies, leaving residents vulnerable to receiving unwanted medical interventions.
Failure to Include Code Status in Care Plans
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered care plan that included the code status for three residents out of a sample of 22. The facility's policy mandates that a comprehensive care plan should be developed within seven days after the completion of the Minimum Data Set (MDS) assessment, incorporating all care area assessments triggered by the MDS. However, the care plans for Residents #11, #20, and #25 did not include their code status or preferences, despite these being documented in their medical records. Resident #11 was documented as Full Code, while Residents #20 and #25 were documented as Do Not Resuscitate (DNR), yet these critical details were missing from their care plans. Interviews with facility staff, including a Certified Nurse Aide (CNA), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the MDS Coordinator, revealed a consensus that the code status should be included in the care plans. The CNA expressed concern that the absence of code status information could delay care or result in actions contrary to the residents' wishes. The MDS Coordinator acknowledged the oversight and admitted responsibility for ensuring that code status is included in the care plans upon admission and updated as necessary. The administrator was unaware of the missing code statuses and confirmed that the MDS Coordinator was responsible for updating the care plans.
Failure to Update Care Plans for Dialysis and Code Status Changes
Penalty
Summary
The facility staff failed to review and revise the care plan for a resident who began dialysis and for another resident who had a change in code status. The facility's policy mandates that a comprehensive care plan be developed and updated within seven days of a comprehensive assessment, and whenever there is a change in the resident's condition. However, the care plan for a resident with End Stage Renal Disease was not updated to include new dialysis orders after the resident returned from the hospital. Interviews with the LPN, DON, and MDS coordinator revealed that the care plan should have been updated immediately to reflect the new dialysis orders, but this was not done. In another instance, a resident's care plan did not reflect a change in code status from Full Code to Do Not Resuscitate (DNR). The facility's policy requires that code status be included in the care plan upon admission and updated with any changes. Interviews with the CNA, LPN, DON, and MDS coordinator indicated that the omission of the code status in the care plan could lead to staff not following the resident's wishes in an emergency. The MDS coordinator acknowledged the lapse in updating the care plan with the new code status. The administrator and staff interviews consistently highlighted the expectation that care plans should be updated promptly with any changes in a resident's condition or orders. The responsibility for ensuring these updates lies with the MDS coordinator, who admitted to missing the updates in both cases. This oversight resulted in care plans that did not accurately reflect the current medical needs and preferences of the residents involved.
Failure to Monitor and Store Controlled Medications Safely
Penalty
Summary
The facility failed to ensure that medications, particularly controlled substances, were monitored and stored safely and effectively. The staff did not maintain control logs for three controlled medications in the destruction cabinet, as required by the facility's policies. The Controlled Substances policy mandates that nursing staff count controlled medications at the end of each shift, with both the incoming and outgoing nurses participating in the count and documenting any discrepancies. Additionally, the Discarding and Destroying Medications policy requires that controlled substances be disposed of within three days of discontinuation. However, the control logs for residents' medications, including Hydrocodone/APAP and Lorazepam, were not consistently documented over several days, and the destruction cabinet contained medications that had not been properly logged or destroyed. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN), Registered Nurse (RN), and the Director of Nursing (DON), revealed a lack of adherence to the facility's policies. The ADON admitted to not checking the destruction cabinet due to increased responsibilities after the DON's departure. The LPN and RN acknowledged not signing the controlled logs, with the RN unaware of the medications in the cabinet. The DON confirmed that staff should sign the controlled log and count medications at shift changes, even if they are in the destruction cabinet. The administrator also stated that controlled medications should be counted at every shift change but was unaware of the existence of the destruction cabinet or who was responsible for checking it.
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Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Osage Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Osage Beach Rehabilitation And Health Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Arrowhead Senior Living Community | 4.2 mi | ★★★★★ | 0 | 0 |
| Lake Regional Health Systems | 5.4 mi | ★★★★★ | 3 | 0 |
| Ozark Rehabilitation & Health Care Center | 5.5 mi | ★★★★★ | 0 | 0 |
| Miller County Care And Rehabilitation Center | 9.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.