Health inspection·September 13, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based 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. Findings include: R2's admission Record documents admission date of 8/2/2023 including diagnoses of Muscle weakness, lack of coordination, abnormal posture, Cerebral Infarct followed by aphasia, dysphagia, abnormalities of gait and mobility, and Alzheimer. R2's MDS (Minimum Data Set) dated July 24th, 2024, includes BIMS (Basic Interview for Mental Status) score of 4 indicating severe cognitive impairment. Section GG indicates R2 is a set up for eating, partial/moderate assistance is needed for toileting, bathing, dressing and personal hygiene. R2 requires supervision or touching assistance with ambulation. R2's Care plan includes a focus date 3/14/2024, that documents R2 requires restorative nursing for ambulation to maintain or increase current level of function related to limited ability to ambulate. Interventions include ambulate R2 with a wheeled walker as often as opportunity presents itself daily dated 3/14/2024. Care plans focus for falls documents; R2 is at potential risk for falls and injury due to right tibia fracture, unsteady gait/mobility, generalized weakness, Alzheimer's, history of stroke, pain, use of medications with interventions that include R2 to ambulate to dine and to bathroom with supervision, stand by assist with front wheeled walker and to ambulate using front wheeled walker to bathroom with CNA (Certified Nurse Assistant). R2's MORSE Fall Scale reports dated 9/7/2024, 7/25/2024, 4/24/2024, and 1/15/2024 assessment scores indicating R2 has been a high fall risk on all assessments. R2's Fall During Staff Assist dated 9/7/2024, documents nursing description: resident being walked by staff with a gait belt back to her room following dinner. Resident got to her doorway and legs gave out and resident was lowered to the floor. Resident description: resident stated that she was not hurt, and she didn't know why her legs gave out, resident stated her shoes were not slick. Document states no injuries observed at time of incident. Document titled Incident Witnessed Statement dated 9/7/2024 at 7:30 PM documents I was walking her to her room with her walker, gait belt on her and she started getting weak as we went into her doorway, so I slowly lowered her to the ground and waited for a CNA (Certified Nurse Assistant) to come help and then she got the nurse, and we helped her back into bed. This document is signed by V9 RA (Resident Assistant). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145386 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southgate Health Care Center 900 East Ninth Street Metropolis, IL 62960 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)