Inspection Reports for
Southgate Living Center
500 TRUMAN BLVD, CARUTHERSVILLE, MO, 63830-1261
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
13.6 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
147% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
62% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 58
Deficiencies: 7
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, nurse aide training, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to maintain adequate surety bond coverage for residents' personal funds, incomplete and inadequate care plans for residents with respiratory needs, failure to complete comprehensive discharge summaries, failure to provide assistance with eating to a resident, failure to follow physician's wound care orders, failure to ensure nurse aides completed training and competency testing within four months, and improper labeling and storage of medications including insulin.
Deficiencies (7)
Failed to maintain surety bond at one and one-half times the average monthly balance of residents' personal funds.
Failed to develop and implement individualized comprehensive care plans addressing residents' respiratory needs.
Failed to complete a comprehensive discharge summary for a discharged resident.
Failed to provide assistance with eating for a resident who required help, resulting in another resident feeding him.
Failed to follow physician's wound care orders, resulting in multiple missed dressing changes.
Failed to ensure nurse aides completed training and competency testing within four months of hire.
Failed to ensure medications and biologicals were properly labeled and stored, including multiple opened insulin pens and vials that were unlabeled and undated.
Report Facts
Facility census: 58
Average monthly balance of residents' personal funds: 66606.98
Approved bond amount: 99000
Required bond amount: 100500
Missed wound care opportunities: 5
Missed wound care opportunities: 6
Missed wound care opportunities: 5
Missed wound care opportunities: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse K | Licensed Practical Nurse | Named in wound care and medication labeling findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including surety bond, care plans, nurse aide training, and medication labeling |
| Administrator | Administrator | Named in multiple findings including surety bond, care plans, discharge summary, nurse aide training, and medication labeling |
| Certified Nurse Assistant L | Certified Nurse Assistant | Named in feeding assistance deficiency |
| Occupational Therapist M | Occupational Therapist | Named in feeding assistance deficiency |
| Social Services Director | Social Services Director | Named in discharge summary deficiency |
| Dietary Manager | Dietary Manager | Named in feeding assistance deficiency |
Inspection Report
Plan of Correction
Census: 58
Deficiencies: 8
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to identify deficiencies in regulatory compliance at Southgate Living Center and to document the facility's plan of correction for cited deficiencies.
Findings
The facility was found deficient in multiple areas including surety bond security for personal funds, development and implementation of comprehensive care plans, discharge summaries, ADL care for dependent residents, quality of care, facility hiring and use of nurse aides, and labeling/storage of drugs and biologicals. Deficiencies were documented with specific resident cases and policy reviews.
Deficiencies (8)
F570 Surety Bond-Security of Personal Funds: The facility failed to maintain a surety bond sufficient to cover the average monthly balance of residents' personal funds for the last 12 months. The facility census was 58.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement individualized comprehensive care plans with specific interventions for two residents. The facility census was 58.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary for one resident out of two sampled closed discharge records. The facility census was 58.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary assistance with activities of daily living for one resident of three sampled. The facility census was 58.
F684 Quality of Care: The facility failed to ensure residents received treatment and care in accordance with professional standards and person-centered care plans. The facility census was 58.
F728 Facility Hiring and Use of Nurse Aide: The facility failed to ensure nurse aides completed training and competency evaluation programs within required timeframes. The facility census was 58.
F761 Label/Store Drugs and Biologicals: The facility failed to label and store drugs and biologicals in accordance with accepted practices, including expired medications found on the medication cart. The facility census was 58.
A4031 Communicable Disease-Employees: The facility failed to follow infection prevention practices for tuberculosis screenings for six of ten employees. The facility census was 92.
Report Facts
Facility census: 58
Facility census: 92
Average monthly balance of residents' personal funds: 66606.98
Approved bond amount: 99000
Required bond amount: 100500
Inspection Report
Life Safety
Census: 58
Deficiencies: 6
Date: Mar 6, 2025
Visit Reason
The inspection was an Emergency Preparedness survey conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA).
Findings
The facility failed to meet several Life Safety Code requirements including self-closing doors to hazardous areas, grease accumulation on kitchen hood filters, and maintenance of portable fire extinguishers. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K223 Doors with Self-Closing Devices: The facility failed to ensure doors to hazardous areas had self-closing devices and those with self-closures had no impediments to closing and latching properly.
K324 Cooking Facilities: The facility failed to ensure the range hood was free of grease and debris buildup, potentially affecting all residents and staff.
K355 Portable Fire Extinguishers: The facility failed to ensure portable fire extinguishers were maintained according to NFPA 10, including inspection of the kitchen hood suppression system since November 2024.
A2016 Fire Extinguisher UL/FM Monthly Check: Fire extinguishers did not bear required labels and documentation of monthly pressure checks was not maintained.
A2017 Range Hood Certification: The range hood and extinguishing system were not certified twice annually as required.
A2055 Door Devices: Doors providing separation between floors lacked required electromagnetic hold-open devices interconnected with smoke or fire alarm systems.
Report Facts
Facility census: 58
Inspection Report
Routine
Census: 64
Deficiencies: 9
Date: Feb 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, facility environment, and food safety at Southgate Living Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accurate resident assessments, comprehensive care plans, trauma-informed care, medication administration accuracy, medication error rates, proper labeling and storage of medications, food safety and sanitation, and infection prevention and control practices.
Deficiencies (9)
Failed to provide a safe, clean, comfortable homelike environment with multiple maintenance issues including holes in doors, broken closet doors, exposed sharp metal, and unclean areas.
Failed to accurately code the Minimum Data Set (MDS) assessments for four residents, missing key diagnoses and PASARR documentation.
Failed to implement complete care plans with specific interventions for three residents, including failure to address PTSD and medication use.
Failed to provide trauma-informed and culturally competent care for two residents with PTSD, including failure to identify triggers and provide supportive interventions.
Failed to provide appropriate treatment and services to residents diagnosed with dementia, with care plans lacking specific problems, interventions, or goals.
Failed to maintain medication error rates at 5% or less, with 12 errors out of 39 opportunities (30.77%) involving two residents.
Failed to ensure drugs and biologicals were labeled properly and stored securely; one resident kept medications at bedside without physician order or documented assessment.
Failed to procure, store, prepare, distribute, and serve food under sanitary conditions, with multiple sanitation and maintenance issues in kitchen and food storage areas.
Failed to provide and implement an infection prevention and control program, including improper wound care practices, failure to perform hand hygiene during medication administration, and inadequate infection control during glucose monitoring.
Report Facts
Medication error rate: 30.77
Residents sampled: 16
Facility census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in wound care infection control deficiency for contaminating scissors and dressings |
| RN A | Registered Nurse | Named in medication administration and infection control deficiencies for medication errors and failure to perform hand hygiene |
| Director of Nursing | Interviewed regarding expectations for care plans, medication administration, and infection control | |
| Administrator | Interviewed regarding expectations for care plans, medication administration, facility maintenance, and infection control | |
| Assistant Director of Nursing | Interviewed regarding resident medication self-administration and bedside medication storage | |
| Dietary Manager | Interviewed regarding kitchen sanitation and cleaning practices | |
| Dietary Aide F | Interviewed regarding kitchen cleaning expectations and challenges |
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 10
Date: Feb 9, 2024
Visit Reason
The document is a Plan of Correction submitted by Southgate Living Center following a survey conducted on February 9, 2024.
Findings
The facility was found deficient in multiple areas including safe and comfortable environment, accuracy of assessments, comprehensive care plans, trauma-informed care, treatment for dementia, medication error rates, medication labeling and storage, food safety, and infection prevention and control. Deficiencies affected multiple residents and involved environmental, clinical, and administrative issues.
Deficiencies (10)
F584 Safe Environment. The facility failed to provide a safe, clean, comfortable home-like environment with multiple maintenance issues such as holes in walls, missing closet doors, exposed sharp metal, and damaged fixtures affecting residents.
F641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set (MDS) for four residents and lacked a policy related to MDS accuracy.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to implement care plans with specific interventions for three residents, including measurable objectives and timeframes.
F699 Trauma Informed Care. The facility failed to provide trauma-informed care for residents with PTSD, including education and documentation of triggers and interventions.
F744 Treatment/Service for Dementia. The facility failed to provide appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents with dementia.
F759 Free of Medication Error Rates 5 Percent or More. The facility failed to maintain a medication error rate below 5%, with 12 errors out of 39 opportunities affecting two residents.
F760 Residents are Free of Significant Med Errors. The facility failed to ensure two residents were free of significant medication errors, including failure to administer medications as ordered.
F761 Label/Store Drugs and Biologicals. The facility failed to ensure drugs and biologicals were labeled and stored according to accepted practices, affecting one resident.
F812 Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to maintain sanitary conditions in food storage, preparation, and service areas, increasing risk of foodborne illness.
F880 Infection Prevention & Control. The facility failed to maintain proper infection control practices for wound care, hand hygiene, and glucose monitoring for multiple residents.
Report Facts
Facility census: 64
Medication error rate: 30.77
Medication error opportunities: 39
Medication errors: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Anne Ulantha | Administrator | Signed the Plan of Correction documents |
| Director of Nursing | Mentioned in relation to education and monitoring of MDS accuracy, medication administration, and care plans | |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Mentioned in relation to knowledge of residents with PTSD diagnosis |
| Licensed Practical Nurse (LPN) B | Licensed Practical Nurse | Mentioned in relation to knowledge of residents with PTSD diagnosis |
| Director of Nursing (DON) | Director of Nursing | Mentioned in relation to expectations for care plans and medication administration |
| Certified Nursing Assistant (CNA) E | Certified Nursing Assistant | Mentioned in relation to knowledge of resident PTSD diagnosis |
| Registered Nurse (RN) A | Registered Nurse | Mentioned in relation to medication administration and hand hygiene failures |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Mentioned in relation to medication assessment and education |
| Dietary Aide F | Dietary Aide | Mentioned in relation to cleaning expectations in kitchen |
| Dietary Manager | Dietary Manager | Mentioned in relation to kitchen cleaning and refrigerator maintenance |
Inspection Report
Life Safety
Census: 65
Deficiencies: 2
Date: Feb 9, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations, specifically focusing on emergency preparedness and cooking facilities.
Findings
The emergency preparedness portion of the survey resulted in no deficiencies. However, the facility failed to ensure the range hood was free of grease accumulation, which potentially affected all residents and staff. The range hood filters were observed laden with grease.
Deficiencies (2)
42 CFR 483.70(a) The facility does not meet the applicable provisions of the 2012 Life Safety Code of the NFPA related to cooking facilities. The range hood was found laden with grease, posing a fire hazard.
19 CSR 30-85.022(9) Range Hood Certification is not met as the range hood and extinguishing system were not properly maintained and certified twice annually as required by NFPA 96, 1998 edition.
Report Facts
Facility census: 65
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
The document is a plan of correction related to a deficiency cited during a facility inspection regarding quality of care, specifically the administration of Nitroglycerin to a resident.
Complaint Details
Complaint #MO224286 related to improper administration of Nitroglycerin to Resident #1.
Findings
The facility failed to ensure one resident received treatment for chest pain per accepted standards of practice. The Registered Nurse administered multiple doses of Nitroglycerin without obtaining a physician's order or checking blood pressure prior to doses, resulting in the resident having low blood pressure and requiring hospital treatment.
Deficiencies (1)
F684 Quality of care deficiency: The facility failed to ensure one resident received treatment for chest pain according to accepted standards. The RN administered multiple doses of Nitroglycerin without physician orders or proper blood pressure checks, leading to low blood pressure and hospitalization.
Report Facts
Facility census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication administration finding related to Nitroglycerin doses |
| PA | Physician Assistant | Gave orders related to Nitroglycerin administration |
| DON | Director of Nursing | Interviewed regarding Nitroglycerin administration standards |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly administer Nitroglycerin to a resident experiencing chest pain, resulting in immediate jeopardy to resident health.
Complaint Details
Complaint #MO224286 regarding improper administration of Nitroglycerin to Resident #1, substantiated by findings of immediate jeopardy due to failure to follow standard practice and physician orders.
Findings
The facility failed to ensure proper treatment for Resident #1 by administering multiple doses of Nitroglycerin despite the resident's systolic blood pressure being below 100, contrary to standard practice and physician orders. This led to the resident experiencing severe hypotension and hospitalization. The facility lacked a specific policy for Nitroglycerin administration and corrected the noncompliance on the day of the incident.
Deficiencies (1)
Failure to provide appropriate treatment for chest pain by administering multiple doses of Nitroglycerin without physician orders and without checking blood pressure between doses.
Report Facts
Facility census: 67
Nitroglycerin doses administered: 3
Resident blood pressure readings: 75
Resident blood pressure readings: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Administered Nitroglycerin doses contrary to standard practice and physician orders |
| PA | Physician Assistant | Gave order to administer one dose of Nitroglycerin and call 911 |
| DON | Director of Nursing | Provided standard practice guidance and oversight during incident |
| PCP | Primary Care Physician | Confirmed standard practice for Nitroglycerin administration and nurse expectations |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 10
Date: Jun 10, 2022
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for Southgate Living Center.
Findings
The facility was found deficient in multiple areas including advance directives accuracy, safe environment maintenance, timely submission and accuracy of Minimum Data Set (MDS) assessments, baseline care planning, comprehensive care planning, and proper maintenance of handrails. Several residents' records and care plans were incomplete or inaccurate, and environmental hazards such as damaged ceiling tiles and cracked fluorescent light covers were observed.
Deficiencies (10)
F578 Advance Directives: The facility failed to ensure the accuracy of residents' advance directive preferences and DNR status throughout the medical record for two residents.
F584 Safe Environment: The facility failed to maintain a safe, clean, and homelike environment, including damaged ceiling tiles and cracked fluorescent light covers in multiple areas.
F640 Encoding/Transmitting Resident Assessments: The facility failed to timely submit and accurately encode Minimum Data Set (MDS) assessments for multiple residents.
F641 Accuracy of Assessments: The facility failed to accurately code the federally mandated MDS assessment for one resident.
F655 Baseline Care Plan: The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident.
F656 Development/Implementation of Comprehensive Care Plan: The facility failed to develop and implement a comprehensive person-centered care plan for one resident, including measurable objectives and interventions.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide consistent care for activities of daily living (ADLs) for one resident.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure appropriate care and assessment for residents with urinary catheters and incontinence, including proper catheter care and dignity bag use.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to obtain physician orders for oxygen use for two residents and provide care consistent with professional standards.
F924 Corridors have Firmly Secured Handrails: The facility failed to maintain handrails in good repair on corridors, including broken and loose sections.
Report Facts
Facility census: 58
Sampled residents: 17
Days late for MDS submission: 120
Completion dates for plan of correction: Jul 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Purvis | Administrator | Signed the plan of correction documents |
| Director of Nursing | Interviewed regarding documentation accuracy and care plans | |
| Registered Nurse H | Registered Nurse | Interviewed regarding code status documentation |
| Certified Nurse Aide G | Certified Nurse Aide | Interviewed regarding emergency code status procedures |
| Certified Nurse Aide B | Certified Nurse Aide | Interviewed regarding maintenance repair requests |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding maintenance repair requests |
| Housekeeping Manager | Interviewed regarding maintenance repair request forms | |
| Maintenance Supervisor | Interviewed regarding repair request procedures | |
| MDS Coordinator | Interviewed regarding MDS submission delays and accuracy | |
| Certified Medical Technician E | Certified Medical Technician | Interviewed regarding resident care and hygiene |
| Certified Nurse Assistant D | Certified Nurse Assistant | Interviewed regarding resident care and gait belt use |
| Certified Nurse Assistant F | Certified Nurse Assistant | Interviewed regarding resident care and gait belt use |
Inspection Report
Life Safety
Census: 58
Deficiencies: 2
Date: Jun 10, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain the range hood filters free from grease buildup and failed to maintain the sprinkler system in proper working order, including dust-coated sprinkler heads. These deficiencies potentially affected all residents and staff.
Deficiencies (2)
K324 Cooking Facilities: The facility failed to ensure the range hood filters were free from grease and debris, posing a fire hazard. Observation showed buildup of grease and dark brown debris on the filters.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the sprinkler system in functioning order, with three sprinkler heads coated in dust and debris. This could affect fire safety for all residents and staff.
Report Facts
Facility census: 58
Completion date for plan of correction: Jul 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Purvis | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Routine
Census: 58
Deficiencies: 10
Date: Jun 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, maintenance, and clinical care in a nursing home facility.
Findings
The facility was found deficient in multiple areas including inaccurate documentation of residents' advance directives, failure to maintain a safe and homelike environment, untimely submission and inaccurate coding of Minimum Data Set (MDS) assessments, incomplete baseline and comprehensive care plans, inconsistent assistance with activities of daily living, improper catheter care, and lack of physician orders for oxygen use. Maintenance issues such as damaged ceiling tiles, cracked light covers, and unsecured handrails were also noted with no repair requests documented.
Deficiencies (10)
Failed to ensure accuracy of residents' advance directive CPR status in medical records for two residents.
Failed to maintain a safe, clean, comfortable, homelike environment including damaged ceiling tiles, cracked light covers, and broken wheelchairs.
Failed to electronically transmit Minimum Data Set (MDS) assessments timely for multiple residents.
Failed to accurately code MDS anticoagulant medication for one resident.
Failed to develop and implement baseline care plan addressing oxygen use for one resident within 48 hours of admission.
Failed to develop and implement a comprehensive care plan addressing smoking safety and gait belt refusal for one resident.
Failed to provide consistent care for activities of daily living including shaving and nail care for one resident.
Failed to ensure appropriate placement and securement of indwelling catheter tubing and drainage bag for one resident.
Failed to obtain physician orders for oxygen use for two residents despite observed oxygen administration.
Failed to maintain handrails on 200 and 400 halls in safe and operable condition with no repair requests documented.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 8
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in resident transfer and gait belt refusal observation |
| CMT E | Certified Medication Technician | Named in resident transfer and ADL care observations |
| CNA F | Certified Nursing Assistant | Named in resident transfer observation |
| RN H | Registered Nurse | Interviewed about code status documentation |
| DON | Director of Nursing | Interviewed about multiple deficiencies including code status, MDS, care plans, catheter care, oxygen orders |
| CNA B | Certified Nursing Assistant | Interviewed about maintenance repair request procedures |
| CNA G | Certified Nursing Assistant | Interviewed about maintenance repair request procedures and emergency code status |
| LPN A | Licensed Practical Nurse | Interviewed about maintenance repair request procedures and ADL care |
| Housekeeping Manager | Interviewed about maintenance repair request procedures | |
| Maintenance Supervisor | Interviewed about maintenance repair request procedures | |
| MDS Coordinator | Interviewed about MDS submission and coding deficiencies |
Inspection Report
Plan of Correction
Census: 58
Deficiencies: 1
Date: Mar 25, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Southgate Living Center following a survey completed on 03/25/2021. It addresses a past noncompliance related to abuse and neglect involving a staff member spitting in a resident's face during the COVID-19 pandemic.
Findings
The facility failed to ensure a resident was free from verbal and mental abuse when a Dietary Aide spat in the resident's face. The facility took corrective action by investigating the incident, suspending and terminating the staff member, and providing mandatory inservice training on abuse and zero tolerance policies.
Deficiencies (1)
F 600: The facility failed to prevent verbal and mental abuse of a resident by a Dietary Aide who spat in the resident's face and used abusive language. The incident was reported to local law enforcement and corrective actions were taken including staff suspension and termination.
Report Facts
Facility census: 58
Sampled residents: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA B | Dietary Aide | Named in abuse incident involving spitting on resident |
| LPN C | Licensed Practical Nurse | Entered hallway and instructed DA B to enter building; reported event to Director of Nurses |
| DON | Director of Nurses | Reported event, took statements, and instructed DA B to write a statement |
| CNA A | Certified Nurse Aide | Witnessed and intervened during abuse incident |
Inspection Report
Routine
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 7
Date: Oct 16, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for Southgate Living Center.
Findings
The facility was found deficient in multiple areas including preparation for safe and orderly transfer or discharge, quarterly assessments, accuracy of assessments, comprehensive care plans, medication error rates, infection prevention and control, and immunization policies. Several residents' records showed missing or incomplete documentation and the facility lacked certain policies and procedures.
Deficiencies (7)
F624 Preparation for Safe/Orderly Transfer/Discharge. The facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge for seven residents.
F638 Quarterly Assessment at Least Every 3 Months. The facility failed to ensure the quarterly Minimum Data Set (MDS) assessments were completed timely for two residents.
F641 Accuracy of Assessments. The facility failed to ensure the accuracy of assessments for three residents, including documentation of tracheostomy care and anticoagulant medication.
F657 Care Plan Timing and Revision. The facility failed to revise and update comprehensive care plans with specific interventions to meet individual needs of two residents.
F759 Free of Medication Error Rates 5 Percent or More. The facility failed to maintain a medication error rate of less than five percent, with an error rate of eight percent observed.
F880 Infection Prevention & Control. The facility failed to maintain infection control practices to prevent infection transmission for two residents and did not provide a policy for insulin pens.
F883 Influenza and Pneumococcal Immunizations. The facility failed to provide information and education regarding pneumococcal vaccines and failed to offer vaccines upon admission to certain residents.
Report Facts
Residents sampled: 18
Medication error opportunities: 25
Medication errors: 2
Medication error rate: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Purvis | Licensed Nursing Home Administrator (LNHA) | Signed the plan of correction and deficiency statements |
Inspection Report
Life Safety
Census: 68
Deficiencies: 7
Date: Oct 16, 2019
Visit Reason
The inspection was conducted to assess compliance with emergency power systems, fire safety, and smoking regulations as part of a life safety code survey.
Findings
The facility failed to maintain an on-site fuel source for the emergency generator, monthly inspections on the kitchen fire extinguishing system, smoke barrier walls free of penetrations, and smoking areas around the facility. These deficiencies potentially affected all residents and staff.
Deficiencies (7)
E 041: The facility failed to maintain an on-site fuel source for the emergency generator, which could affect all residents and staff during an emergency.
K 324: The facility failed to maintain monthly inspections on the kitchen fire extinguishing system, potentially affecting all residents and staff.
K 372: The facility failed to maintain smoke barrier walls free of penetrations, including a one-inch penetration in the 200 hall dining room smoke wall.
K 741: The facility failed to maintain smoking areas around the facility, with large amounts of cigarette butts observed on the grounds and no designated disposal areas.
A 2016: Fire extinguishers were not maintained in accordance with NFPA 10, 1998 edition, including documentation and dating of monthly pressure checks.
A 2054: Smoke section walls and doors were not maintained as one-hour fire-rated barriers as required, with reference to K 372.
A 2057: Designated smoking areas lacked proper ashtrays of noncombustible material and safe disposal methods, with reference to K 741.
Report Facts
Facility census: 68
Inspection date: Oct 16, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Purvis | Administrator | Signed the report and plan of correction |
Inspection Report
Plan of Correction
Census: 70
Deficiencies: 5
Date: Sep 10, 2019
Visit Reason
The inspection was conducted to investigate complaints #MO160128 and MO160064 related to pressure ulcers, urinary tract infections, and ostomy care at Southgate Living Center.
Complaint Details
Complaints #MO160128 and MO160064 triggered the inspection. The complaints involved issues with pressure ulcers, urinary tract infections, and ostomy care. The deficiencies were substantiated as evidenced by the findings.
Findings
The facility failed to prevent and properly treat pressure ulcers, provide appropriate catheter and ostomy care, and maintain adequate physician orders and care plans for residents. Multiple deficiencies were identified related to skin integrity, incontinence, and ostomy care.
Deficiencies (5)
F686: The facility failed to identify and treat pressure ulcers for one resident, and did not provide a policy on pressure ulcers.
F690: The facility failed to provide appropriate care to prevent urinary tract infections for one resident with a suprapubic catheter, including failure to keep the drainage bag below the bladder.
F691: The facility failed to provide adequate ostomy care and physician orders for two residents with colostomy or urostomy, and did not have a policy on ostomy care.
A4074: The facility did not provide personal attention and nursing care consistent with acceptable nursing practice, as evidenced by deficiencies F686, F690, and F691.
A4082: The facility failed to keep residents free from avoidable pressure sores and provide adequate treatment.
Report Facts
Facility census: 70
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Purvis | LNHA | Signed the plan of correction and statement of deficiencies |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 18
Date: Sep 28, 2018
Visit Reason
The inspection was conducted as the most recent standard survey of Southgate Living Center to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, incomplete Medicaid/Medicare notices, inadequate housekeeping and maintenance, failure to screen employees for tuberculosis, incomplete resident assessments, and food safety violations. The facility census was consistently noted as 67 during the survey.
Deficiencies (18)
F577 The facility failed to post the most recent survey results in a place readily accessible to residents and family members, and residents were unaware of survey result locations.
F582 The facility failed to obtain signatures on Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notices for sampled residents prior to discharge.
F584 The facility failed to maintain a safe, clean, comfortable, and homelike environment, including housekeeping deficiencies and damaged resident room fixtures.
F607 The facility failed to ensure Nurse Aide and Family Care Safety Registries were checked for federal indicators prior to employment for one employee.
F636 The facility failed to complete admission Minimum Data Set assessments for one resident.
F655 The facility failed to implement baseline care plans with specific interventions for two residents.
F656 The facility failed to implement comprehensive care plans tailored to individual resident needs for two residents.
F688 The facility failed to provide restorative nursing services as ordered for one resident.
F812 The facility failed to store and distribute food under sanitary conditions, including improper labeling and lack of air gap in ice machine drain.
F836 The facility failed to properly screen residents for tuberculosis and document results for one resident.
A3038 The facility failed to maintain furniture and equipment in good condition, with damaged and heavily soiled items.
A4029 The facility failed to develop and implement policies to screen employees for communicable diseases including tuberculosis.
A4074 The facility failed to provide nursing care consistent with resident conditions.
A7019 The facility failed to properly identify and store food containers to prevent contamination.
A7042 The facility failed to maintain ice storage bins with proper air gap to prevent contamination.
A8002 The facility failed to post noncompliance notices in a conspicuous location as required.
A8008 The facility failed to inform residents or representatives of services and charges as required.
A8023 The facility failed to develop and implement policies to prevent mistreatment, neglect, and misappropriation of resident property.
Report Facts
Facility census: 67
Sample size for resident reviews: 17
Sample size for employee reviews: 11
Completion dates for plan of correction: Nov 9, 2018
Inspection Report
Life Safety
Census: 67
Deficiencies: 5
Date: Sep 28, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain clear exit discharges and proper fire resistance ratings around hazardous areas, and did not properly dispose of cigarette ash and used cigarettes. These deficiencies potentially affected all residents, staff, and occupants.
Deficiencies (5)
K271: The facility failed to maintain clear exit discharges in case of emergency; the back door exit in the kitchen was blocked by bread carts.
K321: The facility failed to maintain the fire resistance rating around hazardous areas; doors were propped open with door stops and trash cans.
K741: The facility failed to properly dispose of cigarette ash and used cigarettes; ashtrays and metal containers were not properly maintained.
A2054: Existing licensed facilities lacked attached self-closing devices on all doors providing separation between floors, as referenced by K321.
A2056: Designated smoking areas lacked proper ashtrays and safe disposal of ashtrays, as referenced by K741.
Report Facts
Facility census: 67
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