South County Health Care Center

Inspectors wroteBased on observation, record review and interview the facility failed to provide residents with a clean, comfortable and homelike environment by failing to maintain resident-use areas, bathing areas and common areas in a sanitary and orderly condition. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 80. The facility did not provide a policy for a safe, clean, and comfortable homelike environment. Review of the Resident Council minutes from the 02/11/26 meeting showed a concern with housekeeping and not getting the rooms cleaned. There was no follow-up included. Observation on 06/16/26 at 9:00 A.M., during the initial tour of the facility showed a strong a strong urine odor upon entering. Observations on 06/16/26 at 9:12 A.M. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to maintain hazardous cleaning chemicals in a secure manner to prevent resident access when an unattended one-gallon container of cleaning solution was observed on the floor in a resident accessible hallway. The product was identified by the manufacturer as causing serious eye irritation and potentially harmful if swallowed. The facility's assessment identified that 40 of the 80 residents had behavioral health needs, making resident access to hazardous chemical a foreseeable accident hazard. The facility census was 80. Observation on 06/16/26 at 9:26 A.M., showed an unattended one-gallon container of a purple cleaning solution sitting on the floor in the Countryside 100 and resident-accessible hallway. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide wound care and medications as ordered for one resident (Resident #1) out of 10 sampled residents. The facility census was 82. The facility policy titled, Transcription of Orders and Following Orders, dated May 2024, showed:- The Licensed/Registered nurse will review electronic medication administration records (MARs) and treatment administration records (TARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission and etc.;- If a medication is marked as not given, the reasoning for not being given should be explained in the progress notes and the Resident Care Coordinator (RCC), the Director of Nursing (DON), Assistant Director of Nursing (ADON), Registered Nurse (RN), and the Administrator must be notified. [...]

Inspectors wroteBased on closed record review and interview, the facility failed to provide bathing/showers for one resident (Resident #1) of 10 sampled residents. The facility census was 82. The facility policy titled Resident Showers and dated June 2024, directed staff to: - Assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice;- Provide residents with showers as requested or as per facility schedule protocols and based upon resident safety; The facility did not provide a resident shower/bathing schedule. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect three residents (Residents #1, #2, and #3) of three sampled residents from sexual abuse when the Assistant Director of Nurses (ADON) offered and provided his/her personal medications to the residents in exchange for sexual activity and inappropriate touching. The facility also failed to protect Resident #1, with a history of substance abuse, from abuse when the Activities Director (AD) took the resident in his/her personal vehicle to purchase marijuana. The AD and resident then used the marijuana together while in the vehicle. The facility census was 86. The administration was notified on 3/25/26 at 1:30 P.M. and 3/26/26 at 1:00 P.M. of the Immediate Jeopardy situations which began on 03/18/26. The IJ was removed on 3/26/26, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of food-borne illness. This had the potential to affect all residents. The facility census was 92. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond (a purchased bond for security of residents' personal funds) sufficient to ensure the protection of resident funds. The facility census was 92. Review of the facility's Resident Trust policy, last reviewed 06/12/25, showed:-The facility shall allow residents to access personal possessions and funds during regular business hours, Monday through Friday;-The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed;-The facility shall provide assurance of financial security by means of a surety bond. The bond shall be in an amount equal to at least one and one-half times the average total of the reconciled monthly balances. A copy of current bond shall be kept in a file in the facility by the Resident Trust Clerk. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 92. Review of the facility’s policy titled, “Environmental Rounds”, revised on 06/29/23, showed: - Environmental rounds are to be done daily by the Department Heads; - The Department Head should be inspecting the room for potentially hazardous items and any areas that may not be in compliance with state and federal guidelines; - Environmental rounds include the resident rooms, drawers and bathrooms. Staff will look for items during these rounds which pose a possible risk to residents and/or staff. Review of the facility's Safe and Homelike Environment Policy, last reviewed 06/05/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Certified Background Check (CBC), the Employee Disqualification List (EDL) and Nurse Aide (NA) Registry were checked prior to the employment start date for six employees out of the ten sampled employees. This deficient practice had the potential to affect all residents. The facility census was 92. Record review of the facility's policy titled, Screening-Applicant, Employee, Volunteer and Vendor (Missouri), revised on 06/12/25, showed: - Pre-employment screening; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents' code statuses were listed in the chart, care planned and up to date with the most accurate information for four residents (Resident #1, #16, #65 and #101) out of 19 sampled residents. The facility census was 92. Review of the facility’s policy, “Advanced Directives-Missouri, revised on [DATE], showed: - Individuals have the right to make decisions concerning their care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives as permitted under state statutory and case law; - It is the policy of this facility to follow the directions given by each resident with regard to accepting or refusing medical or surgical treatment to the extent permitted by law; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures by not completing a discharge recapitulation or documentation of the reason for discharge by the physician for one resident (Resident #96) out of three closed record reviews. The facility census was 92. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing, of a transfer or discharge to a hospital, for four residents (Resident #1, #6, #16 and #65) and failed to complete a discharge summary that included a recapitulation of the resident's stay that consisted of but not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for one resident (Resident #98) out of 19 sampled residents. The facility census was 92. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for five residents (Resident #2, #26, #39, #93 and #96) out of 19 sampled residents. The facility census was 92. Review of the facility's “MDS 3.0, Care Assessment Summary and Individualized Care Plans” policy, last reviewed 11/06/23, showed (The MDS 3.0) is an assessment tool that addresses the wholistic person, including functional status, quality of life, and individual plan of care to address and meet needs of the individual resident. 1. Review of Resident #2's medical record showed: - admission date of 05/15/25; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #26, #39, #93, and #101) out of 19 sampled residents. The facility census was 92. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) tubing and drainage bag was maintained by failing to have orders to properly care for one resident (Resident #39) out of 19 sampled residents. The facility census was 92. The facility did not provide a policy. 1. Review of Resident #39's medical record showed:- admitted on [DATE];- Diagnoses of urinary system disorder, low back pain and hematuria (blood in urine), dysuria (painful or uncomfortable urination), and acute kidney failure (kidneys suddenly cannot filter waste from the blood). Review of the Physician's Order Sheet (POS), dated 08/06/25, showed no orders for an indwelling urinary catheter or catheter care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders for continuous positive airway pressure machine (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) settings and tubing changes for one resident (Resident #26) out of one sampled resident with a CPAP and failed to obtain a physician's order prior to oxygen use and orders for nasal cannula (a small, flexible tube that contains two open prongs that sits in the nostrils and attaches to an oxygen source) and humidifier (used to increase the moisture level) changes for one resident (Resident #93) out of one sampled resident with oxygen. The facility census was 92. The facility did not provide a policy.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment and review possible risks and benefits of bed rails prior to installation or use. The facility also failed to obtain informed consent from the resident and/or the resident's representative for two residents (Resident #80 and #101) out of 19 sampled and for two residents (Resident #46 and #74) outside the sample. The facility census was 92. Review of the facility's Proper Use of Bed Rails policy, last reviewed on 06/26/25, showed: - If bed rails are used, the facility will ensure correct installation, use and maintenance of the bed rails; - As part of the comprehensive assessment, components will be considered when determining the resident’s needs and whether the use of bed rails meets the needs; - Components include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent, when medications were administered. There were 27 opportunities with three errors made, for an error rate of 11.11%. This affected one resident (Resident #2) out of 19 sampled residents and one resident (Resident #27) outside the sample, with the potential to affect all residents. The facility census was 92. Review of the facility's policy, Administration of Insulin, revised on 05/14/24, showed:- All insulin will be administered in accordance with physician's orders;- Procedure: Review the insulin order; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures. This deficient practice affected four residents (Resident #10, #16, #47 and #78) out of 19 sampled residents and four residents (Resident #14, #44, #72 and #74) outside the sample, and had the potential to affect all residents in the facility. The facility census was 92. Review of the facility’s Dietary Food Policy, last reviewed 07/05/23, showed: - Meals will be prepared in adequate, yet not excessive amounts for all diets as determined by the current diet census; - The employees with food preparation responsibilities are trained and are able to obtain information from daily menus and determine the proper amount of food required to serve; - Foods will be served at proper temperature to ensure food safety; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care and failed to implement enhanced barrier precautions (EBP) during perineal care (peri care-the cleaning of the genitals and anus of the body) and foley catheter (a small flexible tubing inserted into the bladder to drain urine) care for one resident (Resident #78) out of one sampled resident. The facility census was 92. Review of the facility’s policy, “Enhanced Barrier Precautions”, revised on 05/18/24, showed: - It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention and transmission of multidrug-resistant organisms; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for two residents (Residents #80 and #101) out of 19 sampled residents and two residents (Residents #46 and #74) outside the sample. The facility census was 92. Review of the facility's Proper Use of Bed Rails policy, last reviewed on 06/26/25, showed: - If bed rails are used, the facility will ensure correct installation, use and maintenance of the bed rails; - As part of the comprehensive assessment, components will be considered when determining the resident’s needs and whether the use of bed rails meets the needs; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual competency training on dementia care (care of a resident with an impaired ability to remember, think or make decisions) for three of the three sampled Certified Nurse Aides (CNAs). This deficient practice had the potential to affect all residents. The facility census was 92. The facility did not provide a policy regarding the required annual nurse aide training requirements.1. Review of CNA H's in-service record showed:- A hire date of 12/18/18;- A total of 16 hours of annual in-services dated 01/17/25;- No documented annual dementia care training. 2. Review of CNA I's in-service record showed:- A hire date of 06/19/23;- A total of 16 hours of annual in-services dated 01/10/25;- No documented annual dementia care training. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide access to survey results. This had the potential to affect all residents and visitors. The facility census was 92. Review of the facility's Resident Rights policy, last reviewed 07/05/23, showed:- Resident has the right to examine the results of the most recent survey of the facility and any plan of correction in effect with respect to the facility;- The results must be made available by the facility in a place readily accessible to residents;- The facility must post a notice of their availability. Observations from 08/04/25 through 08/05/25 showed:- On 08/04/25 at 10:00 A.M., no survey binder was found in the reception/entry area;- On 08/05/25 at 1:55 P.M., no survey binder was found in the reception/entry area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nurse staffing data in a clear and readable format, in a prominent place, readily available to residents and visitors, on a daily basis at the beginning of each shift. The facility census was 92. Review of the facility's policy, Nurse Staffing Posting Information Policy, revised on 06/26/24, showed:- The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to administer medications per physician's orders for two residents (Residents #1 and #3) out of five sampled residents. The facility census was 82. Review of the facility's policy titled, Medication Administration Policy, dated 06/26/24, showed: - Administer medication as ordered in accordance with manufacturer specifications; - Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Review of the facility's policy titled, Intravenous Therapy, dated 05/18/24, showed: - Intravenous (IV) documentation is recorded in the nurses' notes and/or Medication Administration Record. 1. Review of Resident #3's medical record showed: - An admission date of 08/19/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 82. Review of the facility's policy, Refrigerators and Freezers, revised November 2022, showed: - Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41° Fahrenheit (F) and freezers keep frozen foods frozen solid; - Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; - Monthly tracking sheets include time, refrigerator temperature, temperature of potentially hazardous food and temperature control for safety (PHF/TCS) food, initials, and action taken. [...]

Inspectors wroteBased on observation and interview, the facility failed to protect residents' right to privacy by not ensuring other residents did not enter the shower room during showers and not providing a shower curtain in the 100 hall shower room. This affected two residents (Resident #37 and #56) out of 18 sampled residents and one resident (Resident #10) outside the sample. The facility's census was 82. The facility did not provide a policy regarding protection of privacy during bathing. Observation on 08/20/24 at 2:00 P.M. and on 08/21/24 at 3:32 P.M. of the 100 hall shower room showed: - The shower located in the front of the room and to the right of the door with no curtain; - The toilet located past the shower on the right side of the room; - Nothing to indicate to those outside the shower room that it is occupied. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use proper infection control techniques during medication administration for two residents (Resident #11 and #66) out of 18 sampled residents and four residents (Resident #44, #47, #58, and #75) outside the sample. The facility's census was 82. Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2019, showed: - This facility considers hand hygiene the primary means to prevent the spread of infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS, a federal mandated assessment to be completed by the facility) for six residents (Resident #13, #35, #41, #48, #60, and #62) out of 18 sampled residents. The facility's census was 75. Record review of the facility's Resident Assessments policy, revised March 2022, showed: - A comprehensive assessment of every resident's needs is made at intervals designated by Omnibus Budget Reconciliation Act (OBRA- federally mandated and must be performed for all residents of Medicare and/or Medicaid certified homes); - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments; - OBRA required assessments - conducted for all residents in the facility: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a specialty care area for two residents (Resident #41 and #63) out of 18 sampled residents. The facility's census was 75. The facility did not provide a policy. 1. Record review of Resident #41's medical record showed: - An admission date of 10/3/19; [...]

Inspectors wroteBased on observation, record review, and interview, facility staff failed to use proper safety techniques to transfer/transport two residents (Resident #21 and #227) out of 18 sampled residents and two residents (Resident #31 and #578) outside of the sample. The facility's census was 75. 1. Record review of Resident #21's quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by the facility), dated 03/02/23, showed: - Requires extensive assistance with two staff for transfers; - Supervision for locomotion (ability to move from one place to another) on and off the unit; - No functional limitation of range of motion (ROM) to the upper or lower extremities; - Requires extensive assistance of one staff with toileting; - Requires a wheelchair for mobility. Observation of Resident #21 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to date the oxygen tubing (a flexible tubing that connects to the oxygen concentrator and delivers supplemental oxygen through the nostrils) and humidifier bottle and failed to have a physician's order for changing and dating oxygen tubing. This practice affected three residents (Resident #30, #41, and #63) out of 18 sampled residents. The facility's census was 75. 1. Record review of Resident #30's Physician's Order Sheet (POS), dated March 2023, showed: - Diagnoses of chronic obstructive pulmonary disease (COPD, lung disease that blocks airflow), obesity, chronic respiratory failure (condition where lungs are unable to get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and congestive heart failure (CHF, condition in which heart does not pump blood as well as it should); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform proper hand hygiene by not washing hands or changing soiled gloves during incontinent care, to use surface barriers to prevent cross contamination of items during resident care, and to ensure a mechanical lift was cleaned and disinfected between resident use for four residents (Resident #30, #41, #67, and #227) out of 18 sampled residents. The facility's census was 75. Record review of the facility's policy titled Perineal Care, revised 2/2018, showed: - Equipment: Wash basin, towels, washcloth, soap and personal protective equipment; - Place equipment on bed side stand; - Wash and dry hands thoroughly; - Fill basin one-half full of warm water. Place at bedside; - Fold the bed spread toward the foot of the bed; - Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet; [...]