Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonebridge Oak Tree during CMS and state inspections, most recent first.
Ice Machine Drains Lacked Required Air Gaps: Surveyors observed the kitchen ice machine drain hose lying on the floor near an uncovered floor drain with black material, and the dining room ice machine drain resting directly on a rusted floor drain cover in an adjacent mechanical room. The facility had no policy on ice machine air gaps, and the Plant Supervisor and Administrator both stated they were unaware the drains needed air gaps.
Staff failed to perform mechanical lift transfers safely for two residents who were dependent on staff for transfers and cognitively impaired. Observations showed the residents suspended in the sling without hands-on guidance or support while the lift was moved, and staff interviews confirmed that two people should be used for lift transfers, with one operating the lift and the other holding or guiding the resident.
The facility staff failed to properly store and label food, maintain hand hygiene, and allow dishes to air dry, leading to potential contamination risks. Undated and unlabeled food items were found, and staff did not consistently wash hands or change gloves between tasks. Wet dishes were stacked without air drying, contrary to facility policy.
The facility failed to properly contain waste, with outside dumpsters left open and waste scattered, and kitchen waste containers left uncovered. The Dietary Manager and administrator acknowledged lapses in responsibility and training, contrary to the facility's infection control policy.
Facility staff failed to obtain physician orders and properly maintain CPAP machines for three residents, leading to unsanitary conditions. Observations showed CPAP masks with debris, and staff interviews revealed a lack of awareness regarding cleaning and maintenance responsibilities. The deficiency highlights a failure in managing respiratory care equipment.
Facility staff failed to remove expired medical supplies and medications from the medication storage room, including Heparin syringes and IV sets. Interviews revealed a lack of clear responsibility for managing expired items, with staff admitting to keeping expired supplies for teaching purposes. The facility's policy requires maintaining medication storage areas in a clean, safe, and sanitary manner, which was not followed.
A resident with osteoporosis experienced a leg fracture after their leg fell from a wheelchair pedal. Facility staff failed to notify the resident's physician and family promptly, as required by policy. The incident was not reported until the following day, despite the resident showing signs of pain and swelling. The physician expected immediate notification due to the resident's frail condition.
Ice Machine Drains Lacked Required Air Gaps
Penalty
Summary
The facility failed to maintain an air gap for two of two ice machine drains. During the Life Safety Code tour, the black drain hose from the kitchen ice machine was observed lying on the floor in a small puddle of water near a floor drain that had no cover and had an accumulation of black material. The white plastic drain from the dining room ice machine was observed passing through a hole in the wall to an adjacent mechanical room and resting directly on a rusted floor drain cover. Review of facility policies showed no policy related to ice machine air gaps. During interview, the Plant Supervisor stated that he and the contracted vendor were responsible for maintaining the ice machines, that the vendor checks and cleans the drain hoses, and that maintenance staff verify the vendor's work, but he did not know air gaps were required. The Administrator stated maintenance staff were responsible for the ice machines, had never heard of an air gap, did not know the drains were on the floor, and expected the vendor to have installed the dining room ice machine correctly.
Mechanical lift transfers performed without hands-on resident support
Penalty
Summary
Facility staff failed to transfer two residents using a mechanical lift in a manner that prevented accidents. The facility policy for mechanical lift use stated that at least two nursing assistants are needed to safely move a resident and that the resident should be gently supported during the move without supporting any weight. The lift manual also stated that some circumstances may require two people to safely operate the lift, and that it is the responsibility of the facility or caregiver to determine whether more than one person is needed at the time of transfer. Resident #21 was assessed as cognitively impaired and dependent on staff for transfers. During observation, the DON and a NA used a mechanical lift to move the resident from a wheelchair to bed, but while the resident was suspended in the sling over the tile floor, the resident was moved without hands-on guidance or support. Staff interviews showed differing understanding of the transfer process, with one NA stating two people should be used for all mechanical lift transfers and that one person should hold onto the resident during the transfer, while the DON stated the second staff member should be nearby or move the wheelchair and did not think the policy required a hand on the resident while suspended. Resident #17 was also assessed as severely cognitively impaired and dependent on staff for transfers. During observation, two staff used a mechanical lift to transfer the resident from wheelchair to bed, but the resident remained suspended without staff guidance or support while the sling and resident rocked back and forth over the tile floor as the lift was moved into position. Staff interviews again confirmed that two people should be present for lift transfers, with one operating the lift and the other holding or guiding the resident, and one CNA stated he/she did not hold the resident because he/she was not paying attention or thinking about it at the time.
Deficiencies in Food Storage, Hand Hygiene, and Sanitization Practices
Penalty
Summary
The facility staff failed to adhere to proper food storage and labeling practices, as observed during a survey. Undated and unlabeled food items, such as cookies, cheese, sour cream, and chicken breasts, were found in various storage areas, including the dry goods pantry, walk-in refrigerator, and freezer. Additionally, food items were improperly stored on the floor, and some were past their use-by dates. The Dietary Manager admitted to lapses in monitoring and documentation of food storage practices, which contributed to these deficiencies. The facility staff also failed to maintain proper hand hygiene and glove use, which are critical to preventing cross-contamination. Observations revealed that staff did not consistently wash their hands for the recommended duration, used the same paper towel to turn off faucets and dry hands, and failed to change gloves between handling raw and cooked foods. Instances were noted where staff touched personal items, such as cell phones, and continued food preparation without performing hand hygiene. The Dietary Manager and administrator acknowledged these lapses and confirmed that staff are trained on these procedures. Furthermore, the facility did not comply with its sanitization policy, as dishes were not allowed to air dry before being stacked in storage. Observations showed wet dishes, including trays, plate covers, and bowls, stacked together, which could promote the growth of foodborne pathogens. The Dietary Manager and administrator confirmed that staff are trained to allow dishes to air dry, yet the practice was not consistently followed.
Improper Waste Management and Containment
Penalty
Summary
The facility staff failed to properly contain waste and refuse, leading to potential issues with rodents and pests. Observations on multiple occasions showed that the right-facing lid of the outside waste dumpster was left open, with paper and food waste scattered on the ground around the dumpster and trailing down a hillside into a wooded area. Interviews revealed a lack of clarity regarding responsibility for maintaining the dumpster area, with the Dietary Manager only recently informed of their responsibility and the administrator acknowledging that no staff had been assigned to routinely inspect and service the area. Additionally, observations in the kitchen showed waste containers by the exit door and dishwashing stations left uncovered and unattended by staff. The Dietary Manager confirmed that waste containers should not be left uncovered when the kitchen is unattended, and the administrator reiterated that staff are trained to keep waste containers covered when not in use. These lapses in waste management practices were contrary to the facility's Infection Prevention and Control-Maintenance Department policy, which mandates proper containment of waste to prevent leakage and pest issues.
Failure to Maintain and Document CPAP Equipment Use
Penalty
Summary
The facility staff failed to obtain physician orders for the use of CPAP machines and non-invasive mechanical ventilation devices for three residents. The facility's policy requires specific documentation and maintenance procedures for CPAP machines, including cleaning and documenting settings and usage. However, the care plans and physician order sheets for the residents did not include necessary details such as scheduled times, settings, or instructions for cleaning and maintenance. Observations revealed that the CPAP masks were left uncovered and unbagged, with visible debris, indicating a lack of adherence to the facility's policy. Resident #26, who has Parkinson's Disease, was observed with a CPAP mask that had dried debris on it. The resident reported self-managing the CPAP machine without knowledge of the settings, and staff did not provide assistance with cleaning or maintenance. Similarly, Resident #9, with severe cognitive impairment and renal failure, had a CPAP mask with a large amount of brown debris, and staff were unaware of the cleaning requirements. Resident #14, who requires assistance due to COPD and other impairments, also had a CPAP mask with brown debris, and staff had not cleaned or maintained the equipment since the resident's admission. Interviews with staff, including a CNA and LPN, revealed a lack of awareness and responsibility for cleaning and maintaining the CPAP equipment. The LPN acknowledged that orders for care and CPAP settings were missing and should have been obtained upon admission. The DON confirmed that staff should clean the CPAP masks daily and store them properly, but this was not being done. The deficiency highlights a failure in the facility's processes for managing respiratory care equipment, leading to unsanitary conditions and potential risks for the residents.
Expired Medical Supplies and Medications Not Removed
Penalty
Summary
The facility staff failed to ensure that expired medical supplies and medications were removed and discarded from the medication storage room. During an observation, it was found that the medication storage room contained several expired items, including a syringe of Heparin, non-coring needles, IV administration sets, and various extension sets and connectors. The facility's policy requires nursing staff to maintain medication storage areas in a clean, safe, and sanitary manner, but this was not adhered to. Interviews with facility staff revealed a lack of clear responsibility for managing expired supplies. An LPN mentioned that all nurses are responsible for removing expired items, but there is no specific staff member assigned to this task. The LPN admitted to not having time to go through the supplies regularly. The DON stated that it is a team effort to remove expired supplies, with no one person assigned, and mentioned that expired supplies are sometimes kept for teaching purposes. The administrator confirmed that nurses are responsible for ensuring expired supplies are not stored with current supplies, but acknowledged that expired items were kept for teaching purposes inappropriately.
Failure to Notify Physician and Family After Resident Injury
Penalty
Summary
Facility staff failed to notify a resident's family and physician after an incident where the resident's leg fell from a wheelchair pedal, resulting in a fracture. The facility's policy requires prompt notification of the resident's physician and representative in case of changes in the resident's condition. However, the incident was not reported until the following day, despite the resident experiencing pain and swelling. The resident, who was cognitively intact and had osteoporosis, required full dependence on staff for transfers and used a wheelchair. The incident occurred when a CNA was propelling the resident back from dinner, and the resident's foot fell off the pedal, causing the leg to bend under the wheelchair. The LPN on duty did not notify the physician or family, as they were preoccupied with another matter and underestimated the severity of the incident. The resident's leg was later found to be bruised and swollen, and the physician was not informed until the administrator intervened. The physician expressed the expectation of being notified promptly in such cases, especially given the resident's frail condition.
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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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Nursing homes near Jefferson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River City Living Community | 0.1 mi | ★★★★★ | 8 | 0 |
| Heisinger Bluffs Healthcare Western Campus | 2.5 mi | ★★★★★ | 12 | 0 |
| Jefferson City Manor Care Center | 2.8 mi | ★★★★★ | 8 | 0 |
| Heisinger Bluffs Rehab And Healthcare Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Stonebridge Villa Marie | 2.8 mi | ★★★★★ | 9 | 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 August 2026) and official state health department websites.