Inspection Reports for
Southgate Living Center
500 TRUMAN BLVD, CARUTHERSVILLE, MO, 63830-1261
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
62% occupied
Based on a March 2025 inspection.
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
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
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
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 |
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