Health inspection·September 26, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few a 14% weight loss in less than 3 months. Findings include: R3's admission Record documents an admission date of 9/6/2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Mild protein-calorie malnutrition, Pulmonary Hypertension, Parkinson's Disease, and Repeated Falls. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13 indicating R3's cognition is intact. Section GG, Functional Abilities, indicates R3 requires set up or clean up assistance with eating. Section K, Swallowing/Nutritional Status, documents that R3 weighs 180 lbs, R3 has had a gain of 5% or more in the last month or a gain of 10% or more in the last 6 months, and R3 is not on a physician-prescribed weight-gain regimen. R3's Monthly Weight Report documents a weight for August 2024 of 181.2 lbs September 2024 of 174 lbs. R3's Weights and Vitals Summary in the Electronic Health Record documents R3's weight on 7/1/24 was 189.2 lbs, 7/8/24 was 187 lbs, 7/15/24 of 183 lbs, 7/22/24 of 180 lbs, 8/5/24 of 181.2 lbs, 8/26/24 was 179 lbs (pounds), on 9/6/24 was 174 lbs, on 9/10/24 was 170.4 lbs, and on 9/23/24 was 166 lbs. A handwritten note on this same report documents a corrected weight of 162 lbs on 9/24/24. The documented weights from 8/26/2024 to 9/24/2024 indicate that R3 had a 9.5% weight loss in less than 1 month. The documented weights from 7/1/24 to 9/24/24 indicate that R3 had a 14% weight loss in less than 3 months. R3's Care plan includes a focus area (with a revision date of 4/27/2024) of R3 was admitted with history of weight loss with frequent poor intakes and diagnosis of malnutrition. IBW (Idea Body Weight) is 151 pounds-163 pounds. The documented Goal (with revision date of 8/14/2024) of R3 will maintain weight of 154 pounds or more through next review with target date of 11/15/2024. R3's Order Summary Report with active orders as of 9/24/24, documents diet of Mechanical Soft Texture, honey consistency liquids and ground meat with an order date of 9/23/2024 and an order dated 9/24/24 for Arginaid 2 times a day for wound healing. There were no other orders documented on the Order Summary Report for nutritional supplements. (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 09/26/2024 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)