Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethesda Southgate during CMS and state inspections, most recent first.
Two residents were subjected to disrespectful and derogatory remarks by CNAs during care, including rough handling and inappropriate comments, such as a staff member responding to a resident's distress with "we all have to go someday" and another using profanity. Both residents' care plans lacked documentation of resident rights, and the facility's policy on resident rights was not fully implemented among all staff.
The facility did not complete the required annual TB screening tests for three employees, as per their infection control policy. The policy requires annual TB testing for all employees and volunteers working over ten hours weekly in LTC settings. The Director of Nursing was unaware of the requirement for a one-step TST, resulting in the oversight.
A facility failed to ensure a resident who self-administered medications had the necessary assessments, physician's order, and care plan. An LPN left a ferrous sulfate tablet with the resident without observing her take it, contrary to facility policy. The resident, admitted with anemia and cognitively intact, had no self-medication administration form or care plan in her records. Interviews confirmed the oversight, highlighting a breach in protocol requiring evaluation and physician's order for self-administration.
A resident with serious medical conditions was emergently transferred to the ER due to low oxygen levels and wheezing, but the facility failed to provide a written transfer notice to the resident's court-appointed guardian. The facility's policy requires such notices to include the reason for transfer, effective date, and appeal rights, but this was not followed.
A resident's pressure ulcer worsened from stage 2 to stage 3 due to inadequate care and prevention measures. The facility failed to document and implement effective interventions, such as hand splints and palm protectors, and initiated treatment without a physician's order. Staff were unable to provide evidence of attempted interventions, violating facility policies requiring physician orders and documentation for wound treatments.
The facility failed to maintain safe water temperatures in the bathrooms of two residents, with temperatures exceeding 120 degrees Fahrenheit. One resident, severely cognitively impaired, could not adjust the water temperature independently, while another, moderately impaired, required assistance to do so. The facility's policy was not followed, and the Maintenance Director was unaware of how the temperature setting reached 130 degrees Fahrenheit.
Failure to Ensure Residents' Right to Dignity and Respect
Penalty
Summary
Two residents experienced derogatory and disrespectful remarks from staff members, in violation of their rights to dignity and respect. One resident, who had severe cognitive impairment and required substantial assistance with transfers, was involved in an incident where a CNA responded to the resident's distress during a transfer by saying, "we all have to go someday" after the resident asked, "are you trying to kill me?" This exchange was witnessed by a receptionist, who reported the CNA's rough handling and inappropriate comment. The resident's care plan did not document resident rights, and the resident later reported no memory of the incident. Another resident, who had no cognitive impairment and was dependent for transfers due to multiple medical conditions including a fractured hip and end stage renal disease, reported that a CNA was rough and rude during care. The resident described being pushed towards the bed during a transfer and being spoken to with profanity in the presence of a visitor. The resident felt disrespected by the staff member's attitude and reported the incident to the Administrator. The care plan for this resident also lacked documentation regarding resident rights. The facility's policy required all staff to be aware of and comply with resident rights, with annual in-services and prompt investigation of any violations. However, the Administrator confirmed that only the involved staff member was inserviced following the incidents, rather than all staff. Both incidents were documented as customer service events related to staff attitude and rough handling, and both residents' care plans failed to include documentation of resident rights.
Failure to Conduct Annual TB Screening for Employees
Penalty
Summary
The facility failed to adhere to its infection control policy by not completing the annual tuberculosis (TB) screening tests for three employees. The policy, dated May 2024, mandates annual TB testing for all employees and volunteers working over ten hours weekly in long-term care settings. The responsibility for conducting these screenings lies with the Infection Preventionist/Employee Health Nurse or their designee. However, there was no documentation of the required annual one-step tuberculin skin tests (TST) for three staff members, hired in 2001, 2011, and 2023, respectively. During an interview, the Director of Nursing (DON) acknowledged that annual health screenings for employees employed for more than a year began in October 2023, following a policy change by the corporate office to align with federal guidelines. The DON was unaware that the one-step TST was still required, leading to the oversight.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident who self-administered medications had the necessary assessments, physician's order, and care plan in place. During a medication pass observation, an LPN placed a ferrous sulfate tablet in a medication cup and left it with the resident, who was sitting in her wheelchair. The LPN exited the room without observing the resident take the medication, which the resident consumed two to three minutes later. The resident, who was admitted with a diagnosis of anemia, was cognitively intact as indicated by a BIMS score of 15 out of 15. Upon review, there was no evidence of a self-medication administration form, physician's order for self-administration, or a care plan for self-administration in the resident's records. Interviews with the DON and the LPN confirmed that the resident had not been assessed for self-administration of medications and that medication should not be left with residents without supervision. The facility's policy requires an interdisciplinary team evaluation and a physician's order before allowing self-administration, which was not followed in this case.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice containing all required information for a resident who was emergently transferred to the hospital. The resident, who had been readmitted to the facility with diagnoses including intracranial hemorrhage, persistent vegetative state, and spastic hemiplegia, was transferred to the emergency room due to low oxygen saturations and wheezing. Despite the urgent medical need for the transfer, the facility did not send a written notification to the resident's court-appointed guardian, as confirmed by the Administrator during an interview. The facility's policy on discharge and transfer, revised in December 2022, requires that written notices include the reason for the transfer, the effective date, and an explanation of the right to appeal. However, in this instance, the facility did not adhere to its policy, as no written notification was provided to the resident's representative. This oversight was acknowledged by the Administrator, who stated that it was her expectation that the facility would follow its policy regarding resident transfers and the provision of written information.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate care and prevention measures for a resident's pressure ulcer, which worsened from a stage 2 to a stage 3 ulcer. The resident, who had a history of pressure ulcers on her left pinky finger, was not provided with effective interventions to prevent the ulcer from reopening and worsening. The facility's documentation revealed inconsistencies and lack of evidence regarding the use of preventive devices and interventions, such as hand splints and palm protectors, which were either not documented or not effectively implemented. The facility also initiated treatment on the resident's pressure ulcer without obtaining a physician's order, which is against the facility's policy. Observations and interviews with staff indicated that the dressing applied to the resident's left hand was done without a physician's order, and there was no documentation of the dressing's application or the resident's noncompliance with preventive measures. The Director of Nursing and other staff members were unable to provide documented evidence of the interventions attempted to prevent the ulcer from worsening. The facility's policies require a physician's order for all wound treatments and emphasize the importance of documentation for wound assessment and interventions. However, the facility failed to adhere to these policies, as evidenced by the lack of documented interventions and the initiation of treatment without a physician's order. This deficiency placed the resident at risk for further complications and highlighted the facility's failure to implement and document appropriate care measures for pressure ulcer prevention and treatment.
Unsafe Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to maintain safe water temperatures in the bathrooms of two residents, resulting in hot water temperatures exceeding 120 degrees Fahrenheit. Resident 51, who was severely cognitively impaired due to Alzheimer's disease and dementia, was able to independently use the bathroom sink but could not adjust the water temperature. During an interview, the resident mentioned that the water was very hot, and the temperature was measured at 130 degrees Fahrenheit. Staff members confirmed that the resident could not adjust the water temperature independently. Similarly, Resident 17, who was moderately cognitively impaired, also had access to a bathroom sink with a water temperature of 128.1 degrees Fahrenheit. Although the resident could turn on the water, she required assistance to adjust the temperature if it was too hot. The facility's policy stated that water temperatures should not exceed 120 degrees Fahrenheit, but the water temperature logs for the past six months showed no documented temperatures at or below this threshold. The Maintenance Director was unaware of how the water temperature setting reached 130 degrees Fahrenheit.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nazareth Living Center | 2.1 mi | ★★★★★ | 4 | 0 |
| Nexus At Columbia | 4.6 mi | ★★★★★ | 3 | 1 |
| Bluebird Wellness And Rehabilitation | 4.7 mi | ★★★★★ | 1 | 0 |
| Delmar Gardens South | 4.9 mi | ★★★★★ | 0 | 0 |
| Woodland Manor Nursing Center | 5 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.