SAINT LOUIS, MO - Federal health inspectors cited Bethesda Southgate nursing home for multiple deficiencies during a July 2024 survey, including dangerously elevated water temperatures in bathrooms used by residents with Alzheimer's disease and dementia. The facility, located at 5943 Telegraph Road, was also cited for wound care documentation failures and gaps in tuberculosis screening for employees. The facility had a census of 110 residents at the time of the inspection.
Bathroom Water Reached 130 Degrees in Dementia Residents' Rooms
During the July 2024 inspection, surveyors identified that bathroom sink water temperatures in the rooms of at least two cognitively impaired residents far exceeded the federally mandated maximum of 120 degrees Fahrenheit. The hot water coming from the facility's water tank had been set to 130 degrees, creating a direct burn hazard for some of the facility's most vulnerable residents.
One resident, identified as Resident 51, had been admitted with diagnoses of Alzheimer's disease and dementia. The facility's own assessment determined that a standard cognitive screening could not even be completed on this individual. Staff documented that the resident had both short-term and long-term memory problems and was severely cognitively impaired when making daily decisions. Despite this, the resident was able to independently reach the bathroom sink using a wheelchair and turn on the faucet.
When asked about the water during an interview on July 7, 2024, the resident stated: "Hot? It blows it out hot." When asked what she did when the water was too hot, the resident said she "hurried up" — indicating she was aware of the dangerous temperature but had no ability to correct it.
An on-site measurement by the Administrator in Training confirmed the water temperature in this resident's bathroom was 130 degrees Fahrenheit — a full 10 degrees above the regulatory maximum.
A second resident, Resident 17, also diagnosed with Alzheimer's disease and dementia, faced a similar situation. This resident was assessed as moderately cognitively impaired with a Brief Interview for Mental Status score of 11 out of 15. The water temperature in this resident's bathroom was measured at 128.1 degrees Fahrenheit.
Staff Confirmed Residents Could Not Protect Themselves
Multiple staff members acknowledged the danger during interviews with inspectors. A Licensed Practical Nurse stated that while Resident 51 could physically reach the sink and turn on the hot water, the nurse did not believe the resident had "the cognitive ability to adjust the water temperature to a warm temperature." A Certified Medication Technician echoed this assessment, confirming the resident "would not know how to turn on the water to adjust it."
For Resident 17, the LPN noted that the resident could turn on the water but would only pull her hand back if it was too hot — a reflexive response that does not prevent initial contact burns. The medication technician similarly stated this resident lacked the cognitive ability to adjust excessively hot water.
The facility's own Administrator confirmed during a July 7 interview that any water temperature above 120 degrees was outside the regulatory range and stated that residents "could receive skin injuries such as burns."
Water Temperature Logs Showed No Readings at the Maximum
Perhaps most concerning was the review of the facility's water temperature monitoring logs. Inspectors examined six months of water temperature records and found no documented temperatures of 120 degrees Fahrenheit — suggesting the facility either was not monitoring sink-level water temperatures at individual fixtures or was not recording the results accurately.
The Maintenance Director told inspectors he had adjusted the water temperature from the hot water tank to the long-term care mixing valve from 130 degrees down to 117 degrees on the day of the inspection. When asked how the temperature had reached 130 degrees in the first place, the Maintenance Director stated: "I don't know."
The facility's own Water Temperature Management policy, revised in July 2024 — the same month as the inspection — states that plumbing fixtures accessible to residents "shall be thermostatically controlled so the water temperature at the fixture does not exceed one hundred twenty degrees Fahrenheit."
Why Water Temperature Regulations Exist
The 120-degree Fahrenheit maximum for nursing home water fixtures is not arbitrary. At 130 degrees, water can cause a second-degree burn in as little as 30 seconds of exposure on adult skin. For elderly residents, the risk is substantially greater. Aging skin is thinner, has reduced blood flow, and has diminished sensation — meaning burns can occur more quickly and may not be immediately felt.
For residents with dementia, the hazard is compounded. These individuals may not recognize the danger, may not have the problem-solving ability to turn off the water or adjust the temperature, and may not be able to clearly communicate that they have been injured. The combination of cognitively impaired residents who can independently access bathroom fixtures and water temperatures exceeding safe limits represents a well-documented and preventable safety failure.
Standard practice in long-term care facilities requires regular monitoring of water temperatures at the point of use — not just at the water heater or mixing valve — because temperatures can vary from fixture to fixture depending on pipe length, mixing valve function, and other factors. The absence of documented temperature checks at individual sinks over a six-month period indicates a systemic gap in the facility's safety monitoring.
Wound Care Documentation Deficiencies
Inspectors also cited Bethesda Southgate under F-tag 686, which addresses the treatment and prevention of pressure injuries. The deficiency was classified at a level of minimal harm or potential for actual harm, affecting few residents.
The inspection reviewed the facility's wound care policies, which outlined detailed protocols for assessing, treating, and documenting pressure injuries and other skin conditions. These policies required weekly wound assessments by licensed nurses, including measurements of wound length, width, and depth, as well as documentation of characteristics such as odor, drainage, tissue color, and surrounding skin condition.
The facility's own policies stated that documentation is "key to show that everything is being done to prevent those avoidable pressure injuries and heal pressure injuries." The policies distinguished between avoidable and unavoidable pressure injuries, noting that a pressure injury is considered avoidable when a facility fails to define and implement appropriate interventions, monitor and evaluate those interventions, or revise them when necessary.
Proper wound documentation serves multiple clinical purposes. It allows the care team to track whether a wound is improving or deteriorating, enables physicians to make informed treatment decisions, and creates an evidence trail demonstrating that the facility provided appropriate care. When documentation is incomplete or inconsistent, clinicians may miss signs of wound deterioration, potentially allowing a Stage 2 pressure injury to progress to a more serious Stage 3 or Stage 4 wound — conditions that can lead to infection, sepsis, and other life-threatening complications.
Tuberculosis Screening Gaps Identified
The facility received a third citation under F-tag 880 for infection prevention and control failures. Inspectors found that three employees lacked documentation of required annual tuberculosis screening tests, despite the facility's policy mandating such screenings.
The three staff members had hire dates spanning from 2001 to 2023, indicating the gap was not limited to recent hires. The facility's TB screening policy, dated May 2024, established guidelines for annual testing of all employees and volunteers working ten or more hours weekly in the long-term care community.
During an interview on July 15, 2024, the Director of Nursing stated that annual health screenings for employees had begun in October 2023, following a corporate policy change aligned with federal guidelines. However, the DON acknowledged she "did not know a one step was still required" — referring to the annual one-step tuberculin skin test.
Tuberculosis remains a significant concern in congregate living settings such as nursing homes. Elderly residents are at elevated risk for TB due to age-related immune system changes, and an outbreak in a long-term care facility can spread rapidly among a vulnerable population. Annual screening of staff members is a fundamental infection control measure designed to identify active or latent TB before it can be transmitted to residents or other employees.
Broader Implications
The deficiencies identified at Bethesda Southgate span three distinct areas — environmental safety, clinical wound care, and infection control — suggesting gaps across multiple departments rather than an isolated failure. The water temperature violation is particularly notable because it combined a known hazard with a population specifically unable to protect themselves, and because the facility's own monitoring systems failed to detect the problem over an extended period.
All three citations were classified at the level of minimal harm or potential for actual harm. The facility is required to submit a plan of correction to the state survey agency addressing each deficiency. Readers can contact Bethesda Southgate or the Missouri state survey agency for information on the facility's corrective actions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethesda Southgate from 2024-07-18 including all violations, facility responses, and corrective action plans.
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