Southgate Health Care Center

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide dependent residents timely ADL (Activities of Daily Living) assistance with toileting/incontinence care for 1 of 3 residents (R1) reviewed for ADL assistance in the sample of 11. R1's admission Record (print date 6/24/26) documented an original admission date of 8/2/23 and included diagnoses of cognitive deficit due to cerebral infarction, Alzheimer's disease, anemia, arthritis, cognitive communication deficit, and repeated falls. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe cognitive impairment. This MDS documents R1 is frequently incontinent of urine and bowel, is dependent upon staff for toileting hygiene, and R1 needs substantial/maximum assistance for toilet transfer. [...]

Inspectors wroteBased on interview and record review the facility failed to notify a medical provider of abnormal vital signs for 1 (R1) of 3 residents reviewed for change in condition in a sample of 6.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide effective pain management for 3 of 3 residents (R1, R2, and R3) reviewed for pain in a sample of 4. This failure resulted in R1, who has a diagnosis of Multiple Myeloma and at the end-of-life stage, not receiving an ordered narcotic pain medication for 6 hours and R1 experiencing intense pain and suffering prior to her death. This failure resulted in Immediate jeopardy, which was identified to have begun on [DATE] when the facility ran out of R1's oral Dilaudid pain medication resulting in R1 experiencing uncontrolled pain. V1 (Administrator), V21 (Regional Clinical Coordinator), V2 (Director of Nursing, and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 2:10PM. [...]

Inspectors wroteBased on observation, interventions, and record reviews, the facility failed to provide appropriate incontinence care and oral care to 3 (R1, R2, R3) of 4 residents reviewed for Activities of Daily Living (ADL's) in a sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure authorized licensed personnel administered medications and failed to ensure accurate documentation of the personnel administering the medications. This failure has the potential to affect all 91 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to only permit authorized individuals access to drugs, biologicals, and controlled Schedule II drugs. This failure has the potential to affect all 91 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure employees working as a licensed staff member had an active professional license. This failure has the potential to affect all 91 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe water temperatures for 3 residents of 12 (R10, R11, R12) reviewed for water temperatures in the sample of 12. This failure has the potential to affect 45 confused and ambulatory residents of the 90 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the kitchen free from roaches. This failure has the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure life sustaining measures were initiated to 1 (R1) of 3 residents reviewed for Cardio-Pulmonary Resuscitation (CPR) in a sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices while providing incontinence care and handling contaminated linens for 2 (R19 and R23) of 8 residents reviewed for incontinence and contact precautions.

Inspectors wroteBased on interview and record review the facility failed to ensure there were sufficient staff to provide timely care and assistance to its residents. This has the potential to affect all 91 residents who currently reside at the facility. Findings Include: The facility Daily Census Report dated 3/6/25 documents 91 residents reside at the facility. 1. R2's admission Record with a print date of 3/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart disease, and muscle weakness. R2's MDS (Minimum Data Set) dated 2/22/25 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R2 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure showers were provided and residents received timely toileting assistance 4 of 6 residents (R2, R3, R12, and R14) reviewed for showers in the sample of 14. Findings Include: 1. R2's admission Record with a print date of 3/6/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart disease, and muscle weakness. R2's MDS (Minimum Data Set) dated 2/22/25 documents a BIMS (Brief Interview for Mental Status) score of 14, which indicates R2 is cognitively intact. This same MDS documents R2 requires partial to moderate assistance of staff for toilet transfers. R2's current Care Plan with a Focus area of, (R2) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity Intolerance, Impaired balance, Limited ROM (Range of Motion) Date Initiated: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of abuse were reported timely to the Administrator and to the State Survey Agency for 2 of 3 (R1 and R13) residents reviewed for abuse in the sample of 14. Findings Include. 1. R1's admission Record with a print date of 3/6/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include multiple fractures, osteoarthritis, and hypertension. R1's MDS (Minimum Data Set) dated 3/5/25 documents R1 has a BIMS (Brief Interview for Mental Status) score of 13, which indicates R1 is cognitively intact. On 3/5/25 at 11:45 AM, R1 stated V13 (LPN/Licensed Practical Nurse) came in his room talking louder than normal and handed him about 16 pills in one cup. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of abuse were thoroughly investigated and residents were protected from possible further abuse for 2 of 3 (R1 and R13) residents reviewed for abuse in the sample of 14. Findings Include. 1. R1's admission Record with a print date of 3/6/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include multiple fractures, osteoarthritis, and hypertension. R1's MDS (Minimum Data Set) dated 3/5/25 documents R1 has a BIMS (Brief Interview for Mental Status) score of 13, which indicates R1 is cognitively intact. R1's current Care Plan documents a Focus area of (R1) has potential for a behavior problem R/T (related to) making false allegations toward staff of assault during routine cares, or bullying, yelling, being belligerent, not cooperative with care at times. Date Initiated: 03/05/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to safely transfer 4 (R1, R2, R3, R11) of 5 residents reviewed for transfers in a sample of 11. This failure resulted in R1 sustaining a large hematoma to the chest wall and requiring a 5-day hospitalization in the Special Care Unit for monitoring and pain management.

Inspectors wroteBased on interviews and record review the facility failed to notify a family member and physician of a change in condition due to injuries of 2 of 4 resident (R1 and R2) in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor weights and implement interventions to prevent weight loss for 1 of 3 (R3) residents reviewed for nutrition in a sample of 8. This failure resulted in R3 sustaining 9.5% weight loss in less than 1 month and. a 14% weight loss in less than 3 months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure completely trained, qualified Certified Nurse Aide staff were present to provide routine care and meet residents' needs, including safe transfer/ambulation assistance for 1 of 3 (R2) residents reviewed for falls in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe mechanical lift transfer to prevent falls for 1 of 3 residents (R3) reviewed for accidents in the sample of 7. This past non-compliance occurred between 7/25/24 and 8/9/24.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately label resident's insulin and eye drops with date of opening and failed to maintain security of controlled medications for 4 of 12 residents (R16, R24, R62, and R64) reviewed for medication labeling and storage in a sample of 39. Findings including: 1. R16's face sheet documented an admission date of [DATE] with diagnoses including: aphasia, muscle weakness, other symbolic dysfunctions, history of falling. R16's Order Summary Report documented a [DATE] order for basaglar kwikpen subcutaneous solution inject 7 units subcutaneously one time a day. On [DATE] at 12:22 PM, R16's basaglar kwikpen was in the medication cart with the seal broken and was not dated with an open date. V21 (Licensed Practical Nurse/ LPN) verified R16's basaglar kwikpen did not have an open date was not sure when it was opened. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a resident's skin on admission for 1 of 5 residents (R4) reviewed for pressure ulcers out of a sample of 39 residents.

Inspectors wroteBased on interview, observation, and record review the facility failed to assess residents for smoking safety to ensure each resident receives adequate supervision to prevent accidents for 2 of 3 residents (R44, R27) reviewed for smoking in the sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide urinary catheter care per current standards of practice for 1 of 4 residents (R18) reviewed for urinary catheters in a sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medication in the form recommended by the pharmacy for 1 of 12 residents (R20) reviewed for medication administration in a sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide wound care per current standards of practice for 3 of 5 residents (R4, R6, and R55) reviewed for pressure ulcers out of a sample of 39 residents.

Inspectors wroteBased on interview and record review, the facility failed to: 1.) offer pneumococcal vaccinations for 2 of 5 residents (R18 and R12) reviewed for immunization in a sample of 39; and 2.) update the facility's Pneumonia Vaccine policy and to include Vaccination Timing for Adults following the most recent recommendations from the Centers for Disease Control and Prevention (CDC). This has the potential to affect any residents eligible to receive the Pneumococcal vaccines.

Inspectors wroteBased on interview and record review, the facility failed to administer the updated (2023-2024 Formula) COVID-19 vaccine to 3 of 5 residents (R18, R67 and R36) reviewed for immunizations in a sample of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize the urgency of a worsening wound and seek immediate evaluation and treatment after noting a significant change in the condition of the wound for 1 (R38) of 7 residents reviewed for wound care in a sample of 77. This failure resulted in R38 developing gas gangrene with underlying osteomyelitis requiring emergent trans-metatarsal amputation and subsequent Chopart's (forefoot and midfoot) amputation and R38 has been placed on hospice care. The Immediate Jeopardy began on [DATE] when R38 was observed to have a significant change to an existing necrotic wound of the left 2nd toe. The new, necrotic area was observed starting between the previous necrotic left 2nd toe, migrating over between the left great toe and down to the bottom of the left foot. [...]

Inspectors wroteBased on interview and record review the facility failed to implement resident admission contracts free of requiring residents to waive their right to hold the facility responsible for losses of personal property. This has the potential to affects all 74 residents residing in the facility.

Inspectors wroteBased on interview, and record review the facility failed to provide 8 hours of daily Registered Nurse coverage. This failure has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to accurately report Registered Nurse hours to the payroll-based journal. This has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide hot/comfortable water temperatures in resident rooms and shower rooms and failed to empty bedside commodes of feces in a timely manner for 67 of 77 residents (R1, R3, R4, R7, R8, R9, R10, R11, R12, R14, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R41, R42, R44, R45, R46, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R61, R62, R63, R64, R65, R66, R67, R68, R69, R70, R71, R72, R73, R128, R278, R279, and R280) reviewed for environment in the sample of 77.

Inspectors wroteBased on interview and record review the facility failed to refer 1 of 1 resident (R26) for a PASARR (Preadmission Screening and Resident Review) level II screening after receiving a new mental health diagnosis review in a sample of 77.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete serial neurologic checks after an unwitnessed fall and have fall interventions in place for 2 of 9 residents (R22 and R40) reviewed for falls out of a sample of 77.