Bethesda Southgate

F-F688)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 265756 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265756 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bethesda Southgate 5943 Telegraph Road Saint Louis, MO 63129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Review of the facility's policy titled, Wounds: Treatment of Pressure and Non-Pressure Injuries, including Staging and Documentation, revised 10/2023 revealed Purpose: To provide guidelines for use in wound Level of Harm - Minimal harm or assessment, treatment, and documentation . It is the responsibility of the Director of Nursing to oversee this potential for actual harm policy procedure. Policy: . A physician's order is required for ALL wound treatment . B. Assessment/Documentation: 1. Any wound is to be assessed by a licensed nurse or licensed practitioner. Residents Affected - Few The location, stage, size, odor, undermining, tunneling, exudates, necrotic tissue, and presence of absence of granulation tissue, peri-wound and wound edge description should be noted and documented in the resident's medical record at least weekly. Wound assessment documentation should be completed for pressure injuries and recommended for any other skin issues of concern. a. Location: Describe the precise location of the wound in anatomical terms. b. Staging: (Pressure Injuries) . 3. Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis. The wound bed is viable, pink, red, moist, and may present as an intact or ruptured serum-filled blister . 4. Stage 3 Pressure Injury: Full thickness tissue loss. Full-thickness loss of skin in which adipose (fat) is visible in the ulcer granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible . c. Size: Measure the wound in centimeters including

the length, width, and depth. Measure wound from 'healed margins to healed margins' vs. 'edge to edge.' . d. Odor: Describe the odor of the wound as none, mild, or foul (after cleaning). e. Color: Describe the color of

the involved area. Note options for documentation here include describing the wound bed (including granulation tissue, slough, or eschar) in terms of color such as pink, red, yellow, white, black, or brown and estimate percentage of colors. f. Surrounding Tissue (Periwound): Assess the surrounding tissue and document the involved areas i.e., inflammation, maceration, or wet wound edges, tenderness, warm or cool to touch, skin turgor, hypertrophic/callused/thickened, or any other finding. g. Drainage: Describe the type, amount, and color of the drainage (exudates). Examples: yellowish green, gray, serosanguinous, etc. - amount: zero, small, moderate, and large. h. Pain: Describe pain related to the wound and incorporate interventions to reduce pain in the care plan. Document interventions and outcomes in the medical record . C. Monitoring of Wounds: . When a wound is present monitoring should include the following: an evaluation of the injury if no dressing is present, an evaluation of the status of the dressing, if present (whether it is intact, if there is drainage, is it or is it not leaking) . All dressings will be dated and initialed by the nurse apply

the dressing . F. Documentation. It is critical that all caregivers document their observations and activities. For example, CNAs are critical to the process by reporting abnormal skin observations, . Nurses also have a variety of documentation responsibilities as indicated throughout and are critical to the process of documenting interventions that have been taken to AVOID pressure injuries . 'Avoidable' means that the resident developed a pressure injury, and that the facility did not do one or more of the following: . Define and implement interventions consistent with recognized standard of practice. Monitor and evaluate the impact of the interventions. Revise the interventions as appropriate . Documentation is key to show that everything is being done to prevent those avoidable pressure injuries and heal pressure injuries .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 265756 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265756 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bethesda Southgate 5943 Telegraph Road Saint Louis, MO 63129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Review of the facility's policy titled, Skin Integrity, Assessment and Prevention of Wounds/Other Skin Conditions, revised 09/2022 revealed, Purpose: To prevent avoidable skin breakdown and pressure injuries, Level of Harm - Minimal harm or provide guidelines for the treatment of impaired skin and guidelines for documentation . Responsibility: It is potential for actual harm the responsibility of the Nurse Manager to oversee this policy . Policy: All resident's will be assessed for the risk of skin breakdown. Risk factors identified will be evaluated. Interventions will be developed and Residents Affected - Few implemented to minimize or stabilize the risk. Interventions will be care planned. Practice: . II. Prevention.

The following guidelines, which should be implemented based on medical history and physical assessment using an interdisciplinary team approach . Abnormal findings will be assessed by a licensed nurse and appropriate interventions and documentation completed by the nurse . 4. Pressure Reduction. Appropriate pressure reducing positioning devices should be used . Contact Rehabilitation Services for evaluation of seating and positioning devices and orthotic devices . E. All assessments, interventions, and outcomes must be documented in the medical record .

Review of the facility's policy titled, Condition Changes, Incidents, Injuries-Reporting of, revised 01/2023 revealed Purpose: To provide an orderly process for reporting changes in condition, incident or injuries involving residents . Responsibility: It will be the responsibility of the licensed nurses to know and follow this policy . When reporting changes in condition or incidents, the following procedure should be followed: 1. Evaluate symptoms and/or injury. Complete overall head to toe assessment . Document assessment and findings on SBAR [Situation, Background, Assessment, and Recommendation] .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 265756 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265756 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bethesda Southgate 5943 Telegraph Road Saint Louis, MO 63129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36898

Residents Affected - Few Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure safe water temperatures in residents' bathrooms/personal sinks were maintained for two of 23 sampled residents (Resident (R) 51 and Resident R17). The residents' bathroom sink hot water temperatures were greater than 120 degrees Fahrenheit (F). This failure placed both residents at risk for skin irritation, redness, pain, and burns.

Findings include:

1. Review of Resident R51's untitled and undated face sheet, provided by the facility, revealed the resident was most admitted to the facility on [DATE REDACTED] with diagnoses which included Alzheimer's disease and dementia.

Review of Resident R51's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/24, provided by the facility, revealed the facility assessed a Brief Interview of Mental Status (BIMS) score could not be obtained on the resident. The facility assessed Resident R51 had short and long term memory problems, and was severely cognitively impaired when making decisions regarding tasks of daily life. The facility assessed

the resident to need partial to moderate assistance for hygiene and could independently use her wheelchair.

During an interview on 07/07/24 at 12:33 PM, when asked if her water gets hot, Resident R51 stated, Hot? It blows it out hot. Resident R51 stated she independently used the sink to wash her hands. When asked what she did when the water temperature got hot, the resident stated she hurried up.

During an observation and interview on 07/07/24 at 1:12 PM, the Administrator in Training (AIT) took the water temperature and stated it was 130 degrees F.

During an interview on 07/07/24 at 5:48 PM, Licensed Practical Nurse (LPN) 3 stated Resident R51 was able to get to

the bathroom sink in her wheelchair independently. LPN3 stated Resident R51 had the ability to turn the hot water on; however, she did not think she would have the cognitive ability to adjust the water temperature to a warm temperature.

During an interview on 07/07/24 at 6:00 PM, Certified Medication Tech (CMT) 2 stated Resident R51 could make it to

the bathroom sink independently and turn on the water. CMT1 stated the resident would not know how to turn on the water to adjust it to a warm temperature.

2. Review of Resident R17 untitled and undated face sheet, provided by the facility, revealed the resident was most recently admitted to the facility on [DATE REDACTED] with diagnoses which included Alzheimer's disease and dementia.

Review of Resident R17's quarterly MDS with an ARD of 06/19/24, provided by the facility, revealed the facility assessed the resident to have a BIMS score of 11 out of 15 which indicated the resident was moderately cognitively impaired. The facility assessed Resident R17 needed partial to moderate assistance with hygiene, and independently used the wheelchair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 265756 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265756 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bethesda Southgate 5943 Telegraph Road Saint Louis, MO 63129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an observation and interview on 07/07/24 at 1:11 PM, the AIT took the water temperature in Resident R17's bathroom and confirmed the temperature was 128.1 degrees F. Level of Harm - Minimal harm or potential for actual harm During an interview on 07/07/24 at 5:48 PM, LPN3 stated Resident R17 could get to the bathroom sink without assistance using her wheelchair. LPN3 stated the resident could turn the water on, and if it was too hot, she Residents Affected - Few would pull her hand back; however, she would need someone to adjust the water temperature for her.

During an interview on 07/07/24 at 6:00 PM, CMT2 stated Resident R17 had the ability to get to the sink independently

in her wheelchair but she would not have the cognitive ability to adjust the water if it was too hot.

During an interview on 07/07/24 at 2:45 PM, the Administrator stated any water temperature above 120 degrees F was out of the regulatory range. When asked about the sink water temperatures that were above 120 degrees F, the Administrator stated it was important to get the temperatures down below the regulatory range for the safety of the residents. When asked what safety concerns there were for residents using sinks with water temperatures above 120 degrees F, the Administrator stated residents could receive skin injuries such as burns.

During an interview on 07/07/24 at 2:49 PM, the Maintenance Director stated he came in today and adjusted

the water temperature coming from the hot water tank to the long term care (LTC) mixing valve from 130 degrees F to 117 degrees F. The Maintenance Director stated the hot water temperature of the residents' sinks should have been below 120 degrees F for the safety of the residents.

During an interview on 07/07/24 at 3:44 PM, when asked how the hot water temperature setting got to 130 degrees F, the Maintenance Director stated I don't know.

Review of the facility's water temperature logs for the past six months revealed no documented water temperatures of 120 degrees F.

Review of the facility's policy titled, Water Temperature Management, revised 07/2024 revealed . Purpose: To achieve the lowest potential for adverse impact of the safety and health of staff, residents, and visitors coming into the organization's facilities. Policy: The facility will insure [sic] that plumbing fixates that supply hot water and are accessible to the residents shall be thermostatically controlled so the water temperature at

the fixture does not exceed one hundred twenty degrees Fahrenheit (120 F) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 265756 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265756 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bethesda Southgate 5943 Telegraph Road Saint Louis, MO 63129

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 30687 potential for actual harm Based on interview and record review, the facility failed to follow their infection control policy when staff failed Residents Affected - Some to complete the annual one step of the employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests for three employees. The census was 110 with 31 in state license beds.

Review of the facility's Tuberculosis Screening and Testing of Employees and Volunteers, dated May 2024, showed the following:

-Purpose: To establish guidelines for consistency in tuberculosis screening and testing for new employees and volunteers and annual testing and assessment for existing employees and volunteers.

-Scope: Level I policy affecting all employees and all volunteers who work ten or more hours weekly in long term care communities which includes skilled nursing.

-Responsibility: It is the responsibility of the Infection Preventionist/Employee Health Nurse or designee to perform annual health screenings.

-There was no documentation regarding an annual one step tuberculin skin tests (TST).

1. Review of Staff Member A's employee file, showed the following:

-Hire date: 1/22/2001;

-No documentation of an annual one step.

2. Review of Staff Member B's employee file, showed the following:

-Hire Date 3/21/2011;

-No documentation of an annual one step.

3. Review of Staff Member C's employee file, showed the following:

-Hire Date: 2/13/2023;

-No documentation of an annual one step.

4. During an interview on 7/15/24 at 12:51 P.M., the Director of Nursing (DON) said an annual health screening is completed for employees employed more than a year. The DON said this started in October, 2023. The corporate office changed the policy in line with the federal guideline. The DON said she did not know a one step was still required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 265756