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 Owensville during CMS and state inspections, most recent first.
Staff failed to use a gait belt while transferring a resident who required substantial assistance, instead lifting the resident under the arms and by clothing, which resulted in a femur fracture. The facility's policies lacked clear direction on gait belt use, and staff interviews revealed inconsistent understanding of safe transfer procedures.
Staff failed to follow medication administration protocols when an LPN prepared insulin for one resident, but the ADON administered it to another resident who did not have a physician's order for insulin. The error was not documented in the medical record as required, and the incident was discovered when the resident's family questioned the insulin administration. Staff interviews confirmed the improper preparation and administration process, as well as the lack of documentation.
A resident ingested another resident's medications after a CMT left a cup of medications on top of the medication cart and became distracted by an LPN's request to check blood glucose. The resident, who was cognitively intact and independent, accessed and consumed medications not prescribed to them, including Haloperidol, Atorvastatin Calcium, and Clozaril. Facility policy required medications to be kept inaccessible and resident identity to be verified, but these procedures were not followed.
An LPN misappropriated a resident's Oxycodone and Lorazepam by removing medication cards from a locked narcotic box, failing to account for the medications, and discarding packaging, as confirmed by video footage and subsequent investigation. The resident, who was cognitively intact and receiving opioid and antianxiety medications for chronic pain, was discharged with fewer medications than documented, leading to the discovery of the deficiency.
Facility staff failed to maintain proper infection control practices during wound and incontinence care, and dietary staff did not adhere to hand hygiene protocols. An LPN placed wound care supplies on unclean surfaces, and both an LPN and a CNA did not change gloves or wash hands between tasks. Dietary staff washed hands inadequately, despite training. The DON and administrator confirmed the importance of proper hand hygiene and clean barriers.
The facility failed to complete baseline care plans within 48 hours for five residents, as required by policy. Interviews with staff, including the DON, an LPN, and the administrator, revealed confusion and lack of accountability regarding the completion of these plans. The admitting nurse was identified as responsible, but the plans were not completed, and nursing leadership was unaware of the issue.
The facility failed to develop comprehensive care plans for residents, neglecting to address critical needs such as oxygen therapy, contractures, PTSD, urinary catheter care, and pressure ulcer prevention. Observations and staff interviews revealed a lack of documentation and awareness, impacting the quality of care provided.
Facility staff failed to document medication administration for five residents, as required by policy. The MARs showed missing documentation for antibiotics, pain relief medications, and nutritional supplements. Interviews with a CMT, an LPN, and the DON confirmed that missing signatures indicate medications were either not given or not documented, potentially leading to incorrect dosages. Affected residents had conditions like osteomyelitis, arthritis, and cognitive impairment.
Facility staff failed to remove expired medications from medication carts and storage rooms. Observations revealed expired acetaminophen, nitroglycerin, and vaccines, among others. Interviews indicated inconsistent procedures for checking and removing expired medications, with staff unaware of the expired items.
A resident with a left hand contracture did not receive appropriate treatment to prevent further ROM decline. Despite hospital discharge notes recommending occupational therapy, the resident's care plan lacked documentation of the contracture and necessary interventions. Observations showed the resident's hand remained contracted without intervention, and staff interviews revealed a lack of awareness and action. The DON acknowledged the oversight, noting the contracture should have been care planned and communicated.
Failure to Use Gait Belt During Transfer Results in Resident Fracture
Penalty
Summary
Facility staff failed to safely transfer a resident, resulting in an accident and injury. Staff did not use a gait belt during the transfer, despite the facility's educational guide directing staff to always use a gait belt for safety. The resident, who was assessed as moderately cognitively intact and required substantial to maximal assistance with transfers, was being moved by two staff members who lifted the resident under the arms and by the clothing, rather than using a gait belt. During the transfer, a popping noise was heard, and the resident sustained a closed fracture of the left femur. The facility's policy on safe lifting and movement did not specify when to use a gait belt, and the resident's care plan did not provide direction regarding gait belt use during transfers. Interviews with staff revealed inconsistent understanding and implementation of safe transfer protocols. One CNA stated they were unsure if a gait belt was required and did not recall receiving in-service training on safe transfers, including during orientation. Other staff, including an LPN and the DON, confirmed that staff are directed to use a gait belt or other transfer equipment, and acknowledged the risk of injury when not using proper equipment. The incident report documented that the staff involved were counseled for not following fall protocol, which resulted in the resident's injury.
Medication Administration Error and Failure to Document
Penalty
Summary
Facility staff failed to administer medications as ordered by the physician when an LPN prepared insulin intended for one resident, but the ADON administered it to a different resident who did not have a physician's order for insulin. The medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, and to document any medication errors in the clinical chart. However, the insulin was prepared for one resident and given to another, and there was no documentation of this medication error in the resident's medical record. The resident who received the insulin was assessed as cognitively intact and had diagnoses including Alzheimer's, hypothyroidism, congestive heart failure, schizophrenia, and diabetes mellitus type II, but did not have a current physician's order for insulin. The error was discovered when the resident's family questioned the administration of insulin, leading to notification of the physician. Interviews revealed that staff were aware of the error but failed to document it as required, and that medication preparation and administration were improperly split between staff due to staffing shortages.
Resident Ingests Another Resident's Medications Due to Medication Cart Error
Penalty
Summary
Facility staff failed to prevent an accident when a resident ingested another resident's medications. The incident occurred when a certified medication technician (CMT) was preparing medications for one resident and placed the cup of medications for a second resident on top of the medication cart. While the CMT was distracted by a request from an LPN to check the LPN's blood glucose, the first resident reached over, picked up the cup containing the second resident's medications, and ingested them. The facility's medication administration policy required staff to verify resident identity three times before administering medication, ensure the right medication, dosage, time, and route, and to keep medications inaccessible to residents by not leaving them on top of the cart. In this case, the CMT did not follow these procedures, as the medications were left on top of the cart and accessible to residents, and the CMT was distracted by another task during medication administration. The resident who ingested the wrong medications was assessed as cognitively intact and independent with ambulation. The medications ingested included Haloperidol, Atorvastatin Calcium, and Clozaril, none of which were ordered for this resident. Following the ingestion, staff assessed the resident, monitored vital signs, and notified the appropriate medical personnel.
Misappropriation of Resident's Controlled Medications by LPN
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's controlled medications when an LPN removed and failed to account for a significant quantity of Oxycodone and Lorazepam. The resident, who was assessed as cognitively intact and experiencing chronic pain with an intensity level of seven, had an active order for Oxycodone-Acetaminophen but no documented order for Lorazepam. Pharmacy records indicated that 120 tablets of Oxycodone were delivered, and upon discharge, staff documented releasing 49 tablets of Oxycodone and 25 tablets of Lorazepam to the resident. Subsequent investigation revealed discrepancies in the medication count and missing medications after the resident's discharge. Video footage showed the LPN removing three medication cards from a locked narcotic box, placing them in the medication cart, and then leaving the medication room with a full card and the medication sign-out sheet. The LPN was later observed disposing of items in a shred bin and trash, which were later identified as the top of the medication card and an empty medication card, respectively. The incident was brought to the facility's attention when the resident's spouse reported missing medications. The DON and administrator reviewed the video footage and confirmed the LPN's actions, which were also documented in a police report. The facility's policy clearly prohibits misappropriation of resident property, including medications, and directs staff to protect residents from such actions by anyone, including facility staff.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility staff failed to maintain proper infection prevention and control practices during wound care and incontinence care for several residents. Specifically, an LPN was observed placing wound care supplies directly on the beds of two residents without establishing a clean field, as required by the facility's policy. In one instance, the supplies were placed on a urine-soaked bed. The LPN acknowledged that supplies should be placed on a clean surface, such as a bedside table, but noted that these tables are often cluttered and inaccessible. Interviews with the Director of Nursing (DON) and the administrator confirmed that wound care supplies should always be placed on a clean barrier. Additionally, the facility staff did not adhere to approved hand hygiene practices during incontinence care. An LPN was observed failing to wash hands or change gloves between dirty and clean tasks while providing perineal care to a resident. Similarly, a CNA did not change gloves or wash hands after handling soiled linens and before touching clean items. Both staff members acknowledged the lapse in proper hand hygiene, and the DON and administrator reiterated the importance of washing hands and changing gloves between tasks to prevent infection. The dietary staff also failed to perform hand hygiene as often as necessary during food preparation and service. Several dietary aides and a cook were observed washing their hands inadequately, scrubbing for only a few seconds, and turning off faucets with bare hands. Despite being trained on proper handwashing techniques, staff admitted to rushing and not following the correct procedures. The Certified Dietary Manager and the administrator confirmed that staff should wash their hands for at least 20 seconds and use a towel to turn off the faucet, highlighting a gap between training and practice.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for five residents out of a sample of 25, as required by their policy. The policy, dated December 2016, mandates that a baseline care plan be developed to meet the resident's immediate needs within 48 hours of admission. This plan is intended to be used until a comprehensive assessment and an interdisciplinary person-centered care plan can be developed. However, the medical records for Residents #1, #2, #6, #28, and #65 did not contain these baseline care plans, indicating a lapse in adherence to the policy. Interviews with facility staff, including the Director of Nursing (DON), Licensed Practical Nurse (LPN) S, and the administrator, revealed a lack of clarity and accountability regarding the completion of baseline care plans. The DON acknowledged that the baseline care plans should be completed by the admitting nurse as part of the admission process, but noted that the Assistant Director of Nursing (ADON) had been unable to conduct recent chart reviews. LPN S mentioned that baseline care plans are typically completed and reviewed with the medical chart or primary care and family, but was unsure of who was responsible for ensuring their completion. The administrator, who had been at the facility for five months, also stated that the admitting nurse is responsible for completing the care plan, with nursing leadership ensuring its completion, but was unaware of the missing care plans.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific medical and psychosocial needs. For Resident #14, the care plan did not include necessary interventions for oxygen use despite the resident having a diagnosis of respiratory failure and COPD. Observations showed the resident's oxygen concentrator was not being used properly, and interviews with staff revealed a lack of documentation and awareness regarding the resident's oxygen therapy needs. Resident #64's care plan failed to address the resident's contractures, despite observations of the resident's left hand being contracted and causing pain. Interviews with staff indicated that contractures should be documented in the care plan to guide care, but this was not done. Similarly, the care plans for Residents #66, #71, #1, and #17 did not include interventions for their PTSD diagnoses, leaving staff unaware of potential triggers and behaviors to monitor. Additionally, Resident #2's care plan did not include specific instructions for urinary catheter care, leading to inconsistent care practices. Resident #65's care plan lacked details on pressure ulcer prevention and the management of an external fixator, which are critical for the resident's mobility and skin integrity. Interviews with staff and the Director of Nursing highlighted the absence of these essential care components in the care plans, which are necessary for providing appropriate and individualized care to the residents.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility staff failed to document the administration of medications for five residents, as required by the facility's policy. The policy mandates that a Nurse or Medication Aide must document all medications administered to each resident on the Medication Administration Record (MAR) immediately after administration, including the signature and title of the person administering the medication. However, the MARs for several residents showed missing documentation for various medications, including antibiotics, pain relief medications, and nutritional supplements, on multiple occasions throughout August 2024. Interviews with facility staff, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed that the absence of a signature on the MAR indicates that the medication was either not administered or not documented. This lack of documentation could potentially lead to residents receiving incorrect dosages. The residents affected by this deficiency had various medical conditions, such as osteomyelitis, arthritis, severe cognitive impairment, and stroke, which required consistent medication management.
Expired Medications Found in Facility
Penalty
Summary
The facility staff failed to remove and destroy expired medications and biologicals in two of four sampled medication carts and one of two medication rooms. Observations revealed that the charge nurse's medication cart contained expired liquid pain relief acetaminophen, and the 400 hall medication cart contained several expired items, including lubricant eye gel, nitroglycerin, fecal occult blood test developing solution, laxative tablets, and a dressing change kit. Additionally, the medication storage room was found to contain expired Novolog insulin Flex Pen and prefilled syringes of influenza vaccines. Interviews with facility staff indicated a lack of consistent procedures for checking and removing expired medications. A Certified Medication Technician mentioned that pharmacy staff used to check for expired medications but no longer do so. The Licensed Practical Nurse stated that nurses and CMTs are supposed to check for expired medications weekly but was unaware of any expired items. The Director of Nursing mentioned that the pharmacist conducts monthly cart audits and that any nurse can dispose of expired medications, yet was unaware of the expired items found during the survey. This lack of awareness and inconsistent practices contributed to the presence of expired medications in the facility.
Failure to Address Resident's Contracture and ROM Needs
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM) for a resident with a contracture in the left hand. The facility's policy required that residents with limited ROM receive treatment to prevent further decline, and that care plans include specific interventions and therapies. However, the resident's care plan did not document the contracture, goals, or interventions, despite the resident's hospital discharge documentation indicating the need for occupational therapy focused on contracture prevention. Observations over several days showed the resident's left hand remained contracted without any intervention, such as a washcloth, which the resident reported as helpful. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and action regarding the resident's contracture. Staff did not perform ROM exercises or provide any therapy, and there was no communication or documentation in the care plan regarding the contracture. The Director of Nursing (DON) acknowledged the oversight, stating that the contracture should have been included in the care plan and communicated to the MDS Coordinator. The DON also noted that physical therapy determines who receives restorative services, but there was no indication that the resident had been evaluated for such services. The lack of documentation and communication led to the resident not receiving necessary interventions for the contracture.
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Illustrative
What surveyors actually found near you
We read the 12 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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Owensville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gasconade Manor Nursing Home | 2.7 mi | ★★★★★ | 0 | 0 |
| Cuba Manor Inc | 19.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Sullivan | 20.6 mi | ★★★★★ | 1 | 0 |
| Meramec Nursing | 21.4 mi | ★★★★★ | 1 | 0 |
| St James Living Center | 23.1 mi | ★★★★★ | 10 | 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.