Stonebridge Lake Ozark

Inspectors wroteBased on interview and record review, facility staff failed to ensure three Nurse Aides (NA)'s (NA A, NA B and NA C) out of four sampled NAs completed the required nurse aide training program within four months of employment in the facility. The facility census was 48.1. Review of the facility's Nurse Aide Hiring and Competency policy, dated October 2017, showed it is the policy of the facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education They may be employed as full-time and permanent nursing aides but must provide documentation of certification within four months of their hire date. Facility will verify certification through the appropriate state's nurse aide registry. Those who are verified to be enrolled in a State approved nurse aide training and competency evaluation program. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain professional standards of care, when staff failed to document the administration of wound treatments as ordered by the physician for one resident (Resident #2), failed to complete wound assessments for two residents (Resident #2 and #4), and failed to complete weekly skin assessments for two residents (Resident #3, and #4) out of three sampled residents with wounds. The facility census was 59. 1. Review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol policy, revised 03/2020, showed: -Assessment and recognition: the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse when Resident #2 touched Resident #1's chest inappropriately. The facility census was 57. 1. Review of the Facility's Abuse, Neglect, and Exploitation Program Responsibilities policy, dated September 2022, showed: -Each resident has the right to remain free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish; -Sexual abuse is defined as non-consensual contact of any type with a resident. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to revise a comprehensive person-centered care plan for two residents (Resident #1 and #2) out of two sampled residents who had behaviors. The facility census was 57. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated February 2025, showed: -It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality; [...]

Inspectors wroteBased on interview and record review, facility staff failed to review the code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) and failed to obtain physician orders for their preferred code status for two residents (Resident #42 and #159) out of 22 sampled residents. The facility census was 52. 1. Review of the facility's Advance Directives policy, dated [DATE], showed upon admission, the resident will be provided with written information in a manner easily understood by the resident or resident representative concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Prior to or upon admission of a resident, the facility will inquire of the resident, his/her family members about the existence of any written advance directives. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan addressing code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) for three residents (Resident #11, #20, and #25) out of a sample of 22 residents. The facility census was 52. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated [DATE], showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the care plan for one resident (Resident #20) who started dialysis and for a change in code status for one resident (Resident #33) out of a sample of 22 residents. The facility census was 52. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated [DATE], showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool) assessment. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to ensure medications were monitored and stored in a safe and effective manner. Licensed staff failed to maintain the control logs for three controlled medications in the facility's destruction cabinet. The facility census was 52. 1. Review of the facility's Controlled Substances policy, dated December 2016, showed nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing (DON). Review of the facility's Discarding and Destroying Medications policy, dated October 2016, showed disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by resident. 2. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to properly store open food to prevent cross contamination and outdated usage. The census was 45. 1. Review of the facility's Food Receiving and Storage policy, dated July 2014, showed: - Dry foods that are stored in bins will be removed from original packaging, labeled, and dated; - All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Observation on 7/12/23 at 10:50 A.M., showed two bulk bins of white substance unlabeled. Observation of the pantry on 7/12/23 at 3:42 P.M., showed: - Three pound container of kosher salt open, unprotected, and undated; - Container of pepper open, unprotected, and undated; - One pound container cornstarch open and unprotected; - Ziploc bag of bran flakes undated; - Four open loaves of bread undated; - One open hamburger bun undated; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for all residents when they did not properly maintain the wallpaper on walls of the 100 and 200 halls. The facility census was 45. 1. Review of the facility's policy titled, Resident Environmental Quality, dated 2016, showed staff are directed to do the following: -It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public; -Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment; -All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents medical, and nursing needs when they failed to address facial hair preferences for five residents (Resident #1, #7, #19, #28, and #31), failed to address activities for ten residents (Resident #1, #3, #12, #13, #7, #19, #27, #28, #31 and #35) and failed to address behaviors for two residents (Resident #1 and #28). The facility census was 45. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed staff were directed to do the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use hand hygiene during incontinence care for one resident (Resident #3). The facility census was 45. 1. Review of the facility's policy titled, Hand Hygiene, undated, showed staff were directed to do the following: -All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors; -Use either soap or water or an Alcohol Based Hand Rub (ABHR) before applying and after removing personal protective equipment (PPE), including gloves. Observation on 07/13/23 at 9:47 A.M., showed Certified Nurse Aide (CNA) A and CNA F entered Resident #3's room to provide perineal care. [...]