Health inspection·October 17, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/9/2024 at 10:24AM, V3 stated she came in the room on 10/4/2024 and the daughter was in the room and R2 told her about the incident and V3 reported it as well. V3 stated the shoulder has not affected R2's therapy at all. V3 stated R2 doesn't complain of pain to her during therapy. On 10/9/2024 at 1:38PM, V5 CNA/Transportation (Certified Nurse Assistant) stated she had strapped R2 in the back of the van with the straps in place. V5 stated as she was pulling out from a stop light the wheelchair flipped back and the resident stayed in the wheelchair and fell backwards. V5 stated she was on the interstate, so she had to pull off and help the resident back into the wheelchair. V5 stated R2 denied any pain or injuries. V5 stated when she returned to the facility, she took R2 to her room and helped her into bed. V5 stated she forgot to tell anyone about the incident. Document titled Witnessed Fall dated 10/3/2024 at 4:30 PM documents, Incident location: out of facility/during transport and person preparing report is V8 DON (Director of Nursing). Incident description: On 10/4/2024 at approximately 9:30 AM it was reported to DON that resident was stating that while she was being transported back to facility via transport van that her wheelchair tipped all the way over backwards. This was not reported to nursing staff that she had a fall in van. R2 stated My chair tipped over backwards; the girl lifted me back up. Immediate action taken: After speaking to CNA/transport driver she stated that yes, her wheelchair tipped over backwards when she hit her breaks. Floor nurse was notified of resident's statement that she had fallen in wheelchair yesterday. She was assessed by nurse immediately after being informed, noted bruise to back of shoulder, no swelling, did complain pain at site. MD (Medical Doctor) notified for x ray, obtained. Documents MD notified on 10/4/2024 at 10:00AM and Family member notified on 10/4/2024 at 2:00PM. Written statement signed by V5 documents incident occurred on 10/3/2024 at approximately 3:30PM. Incident described in written document including R2 did complain that her shoulder hurt, and she checked her shoulder to see if anything was wrong with it, there was nothing wrong. Document also includes documentation of Did not report incident to the nurse. 2. R1's admission Record documents an admission date of 2/28/2024. Document titled Medical Diagnoses include fracture of femur, Atherosclerotic Heart Disease, Hyperlipidemia, Abnormal Posture, R1's MDS (Minimum Data Set) dated 9/9/2024 includes a BIMS (Brief Interview for Mental Status) score is 5 indicating severe cognitive impairment. Section GG of MDS documents Functional Limitation in Range of Motion R1 has impairment to both sides of upper extremities, and impairment on one side of Lower extremity. Mobility devices used is a wheelchair. Documentation includes R1 is Dependent for Bed mobility, sit to lying, lying to siting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and tub/shower transfer. R1 is dependent on staff for wheelchair mobility. R1's Care plan documents Focus R1 requires restorative nursing for dressing and /or grooming related to decreased ability to perform ADLs (Activities of Daily Living) with revision date of 2/29/2024, Intervention encourage and assist R1 in performing upper and lower body dressing and or grooming with set up and verbal cues as often the opportunity present itself. Incident report for R1, on an untitled document dated 10/3/2024 at 7:30 PM document's location: Shower, person reporting incident was V26 (Registered Nurse/RN). Incident description: Bruise to left chest/breast noted upon shower. Resident denied any complaints of pain to area with palpitation. Immediate action taken description: MD (Medical Doctor), POA (Power of Attorney), and administration on call notified. The same document documents the actual times and dates the notifications were made, on 10/4/2024 at 5:58 AM, V8 DON and Physician notified, and POA notified at on 10/4/2024 at 5:59AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 2 of 11 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 10/17/2024 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)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's Progress Notes dated 10/4/2024 at 5:45 AM documents, Large purple bruise noted to the left chest/breast area with shower. Resident denies pain to area with palpation. Resident denies any knowledge of cause when asked. MD notified. POA called and left message to return call. Admin on call notified. Author V26 RN. On 10/9/2024 at 8:50 AM, V1 (Administrator) stated she wasn't notified of R1's bruising until the morning of 10/4/2024 when the resident was getting sent to the hospital. V1 stated she wasn't aware there was an issue until the family came to the facility on [DATE]. V1 stated she did not get to see the bruising herself. On 10/10/2024 at 5:27PM, V26 (Registered Nurse) stated he was working on 10/3/2024 when he was summons to the shower room to look at R1's left breast. V26 stated R1's left breast was swollen and had some bruising and slight bruising under the left arm. V26 stated he palpated the left breast and R1 didn't show signs of pain. V26 stated he felt the bruising was all superficial and it wasn't a big concern because the resident was on Eliquis. V26 stated he checked on R1 throughout the night by peeking in her room and R1 was resting in bed with no signs of pain or discomfort. V26 stated he last checked on R1 around 4:30AM and she was resting. V26 stated he notified the MD and DON early morning on the 4th and could not reach the family. Facility Policy and Procedure named Accident/Injury/ Change in Condition review date 4/20/2024 reviewed. Documentation for Purpose: It is the policy of the facility to notify the resident's physician of any accident, injury, or significant change in condition. If unable to notify the resident personal physician, the staff will notify the Medical Director. Documentation for Responsibility: It is the responsibility of the staff nurse on shift to notify the family and physician of any accident, injury, or significant change in condition. Documentation of Procedure: 1. The resident's nurse will notify the personal physician of any accident, injury, or change in condition. 2. The resident's nurse will notify the family member and /or guardian of any accident, injury, or change in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 3 of 11 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 10/17/2024 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)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: 1. R1's document titled admission Record documents an admission date of 2/28/2024 and includes diagnoses of fracture of femur, Atherosclerotic Heart Disease, Hyperlipidemia, Abnormal Posture. R1's MDS (Minimum Data Set) dated 9/9/2024 includes a BIMS (Brief Interview for Mental Status) score is 5 indicating sever cognitive impairment. Section GG of MDS documents Functional Limitation in Range of Motion R1 has impairment to both sides of upper extremities, and impairment on one side of Lower extremity. Mobility devices used is a wheelchair. Documentation includes R1 is Dependent for Bed mobility, sit to lying, lying to siting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and tub/shower transfer. R1 is dependent on staff for wheelchair mobility. R1's Care plan documents Focus R1 requires restorative nursing for dressing and /or grooming related to decreased ability to perform ADLs (Activities of Daily Living) with revision date of 2/29/2024, Intervention encourage and assist R1 in performing upper and lower body dressing and or grooming with set up and verbal cues as often the opportunity present itself. R1's Order Summary Report dated 10/11/24 documents in part, Eliquis Oral Table 5 MG (milligram) .give 1 tablet by mouth two times a day for suspected DVT (Deep Vein Thrombosis) in right popliteal vein . Start date: 5/23/24. Incident report for R1, on an untitled document dated 10/3/2024 at 7:30 PM document's Location: Shower, Person reporting incident was V26 (Registered Nurse/RN), Incident description: Bruise to left chest/breast noted upon shower. Resident denied any complaints of pain to area with palpitation. Resident denies knowing how bruise occurred. Immediate action taken description: MD (Medical Doctor), POA (Power of Attorney), and administration on call notified. Predisposing factors include Environmental, Psychological, and Situation, all areas document None. Under notes on this same document dated 10/5/2024, documents, After review of incident statements and knowledge of resident's overall condition, it was reported that resident had large bruise to left breast, originally night nurse felt it was from gait belt. Later that morning day shift nurse came and got DON (Director of Nursing) to eval (evaluate) area. Assessment showed large bruise discoloration to entire left breast, appeared to be very enlarged/swollen, as well with an area protruding around clavicle area. Was also some bruising/discoloration to right breast and side. This discoloration and swelling were a concern, floor nurse instructed to notify MD and send her (R1) to hospital for eval. On 10/9/2024 at 8:50 AM, V1 (Administrator) stated R1's family member transferred her from the wheelchair to the bed then bruising occurred. R1 was sent out to the hospital due to bruising. V1 stated now the family is taking R1 to a different facility. V1 stated the bruising is also from R1 being on a blood thinner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 4 of 11 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 10/17/2024 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few On 10/9/2024 at 10:25AM, V8 (RN) stated she worked on 10/4/2024 the morning that R1 was sent to the hospital for bruising on her chest. The CNA's called me to the room. The areas to R1's chest were dark purple in color and the left breast had what appeared to be a hematoma. V8 stated the incident report was already done by the night nurse. V8 stated there were no reports of falls. V8 stated that R1 was confused. V8 stated we reported to the DON (Director of Nursing), and we sent R1 out to the hospital. V8 stated that R1 was in a lot of pain when she saw her. R1's EMS (Emergency Medical Service) Report dated 10/4/2024 documents at 7:33AM. Responded to (Facility Name) (resident room #) for a [AGE] year-old female with bruising and pain. Upon arrival the patient was in bed, in her room laying on her right side. Nursing staff reported in her rib cage bilaterally and under her breasts and arms bilaterally. Nursing staff did admit to using an under the arm lifting method to transition the patient from the bed to wheelchair. Patient was going to local hospital for evaluation and possible pain control. The patient was responsive to pain, but otherwise did not communicate due to being very hard of hearing. Patient had bruising to above mentioned areas. No vital signs were assessed on the patient during transport due to her pain and lack of communication. The patient did not have any other traumatic injuries noted during the assessment. On 10/9/2024 at 11:44 AM, V10 (emergency room /RN) stated she was the nurse in charge of care for R1 on 10/4/2024. V10 stated R1 was in severe pain to the point it hurt her to even remove the covers to assess her. V10 stated the bruising was really bad and the left breast was swollen at least double the size of the right breast. V10 stated the paramedics that brought R1 in stated the staff informed them that the resident is transferred by way of a bear hug or arm to arm transfer. V10 stated the only way the pain could be controlled was with Fentanyl and stated actually the resident probably needed more pain relief but with her age it would have been too dangerous to give her more. V10 stated R1 was finally able to rest if nobody touched her. V10 stated R1 was admitted to SCU (Special Care Unit) in the hospital for monitoring. V10 stated R1 was on Eliquis which made the bruising probably spread more but it did not cause the actual bruising and swelling. V10 stated R1 was admitted to SCU for close monitoring and pain control. On 10/10/2024 at 8:15 AM, V19 (Primary Care Physician) stated he was the Primary Physician for R1, but R1 was seen by hospitalist V20 (Nurse Practitioner/NP) V20 and V29 (NP) during her hospitalization but he was consulted about the bruising. V19 stated that Eliquis does not cause spontaneous bruising and the bruising had to start with some type of trauma. V19 stated R1's hemoglobin also dropped during the hospital stay and the Eliquis was stopped. V19 stated R1 was in a lot of pain with the areas to the chest wall. V1 stated he was not sure what caused the trauma, but he knows something happened. V19 stated the hematoma even extended into the pectoris muscle. On 10/10/2024 8:20AM, V20 (NP) stated she took care of R1 during her last few days of hospitalization. V20 stated Eliquis does not develop spontaneously bleeding like this. V20 stated, I have not been told what happened to R1 but something trauma related happened, maybe not intentional though. V20 stated it could be someone handled her wrong or transferred her wrong. V20 stated R1's hemoglobin dropped from 8.1 to 7.2 during hospitalization. V20 stated R1 will be discharging to a different facility and on Hospice. V20 stated R1 was in pain that we were controlling with Fentanyl in the ER (Emergency Room) and Morphine and Vicodin while in SCU (Special Care Unit). On 10/14/2024 at 12:05 PM, V18 (NP) stated she saw R1 in the emergency room on [DATE]. V18 stated R1 was in pain and was noted to laying in the fetal position with her hands over her face. V18 stated R1 appeared sleepy due to the IV (Intravenous) medication of Fentanyl that was given for pain. V18 stated the bruising was all over the chest but more significant in the left breast with a hematoma (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 5 of 11 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 10/17/2024 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few noted. V18 stated the family was very upset and was concerned that by the bruising, someone had held down the resident. V18 stated the resident was admitted to the hospital due to the bruising / hematoma, to monitor pain control and to arrange for a safe discharge as family did not want R1 returning to the Long-Term Care facility where she was living. V18 stated R1 is on Eliquis, and this may have made it worse, but some type of injury happened to the left chest/breast for sure. V18 stated some kind of injury occurred to the chest especially the left chest/breast. V18 stated the injury is unknown at this time as the facility denied any type of fall, they had no explanation of how the injury occurred, and this is not bruising from any type of gait belt due to the markings. V18 stated pictures were taken in the emergency room on [DATE], but on 10/5/2024 the bruising was worse and even up into the left shoulder. V18 stated R1's kidney function was good for her age and stayed at R1's baseline during hospitalization and platelets were within normal range. V18 stated if this would have been from a blood thinner than the bruising would not have been to this extent and would have been noted over the whole body but this is not from spontaneous bleeding, plus R1's clotting factors were within normal range. V18 stated when R1 was turned she would have discomfort. V18 stated R1 received pain medications during hospitalization. V18 reported R1 received Morphine 1mg per IV (intravenous) push 2 times on the 5th, 1 time on the 6th, 2 times on the 7th, and had doses on the 8th and the 9th for pain. V18 stated R1 also received Norco 5mg a total of 3 doses throughout hospitalization for pain. V18 stated R1 needed pain medications because when she had to be checked or turned, she would have discomfort. V18 stated R1 had low fluid and food intake during hospitalization and discussion was held with the family about the low intake and pain and family agreed to Hospice Care. V18 stated resident had a decline and with her age Hospice was the best choice and they could control her pain. V18 stated R1 was discharged to a different Long Term Care Facility under Hospice care for Pain control. R1's Imaging Report Cat (computed tomography) Scan of Chest with contrast dated 10/4/2024 for Hematoma of the chest. Findings: There is extensive ground -glass in the subcutaneous fat with collection in the left subcutaneous soft tissues with appears to extend to or potentially involve the left pectus measuring 8.2x4.2x8.9 centimeters. Impression: Large left chest subcutaneous hematoma which may involve the left pectoralis muscle. There is no acute osseous abnormality or fracture identified. R1's emergency room Emergency Progress Notes dated 10/4/2024 documents, Physical Exam, Pain Distress: Moderate, Skin: Reports warm, dry, and other (Extensive bruising on anterior chest wall, more on left breast with tense hematoma. Some bruising noted on the left lateral chest wall and extending to the right side and some of the upper abdomen. Medications given in the emergency room were Fentanyl Citrate 50 mcg (Micrograms) IVP (Intravenous Push) 10/4/2024 at 8:14 AM, Zofran 4mg (Milligrams) IVP 10/4/2024 at 8:14AM, last dose of Fentanyl 50 mcg IVP documented 10/4/2024 at 8:29AM and last dose of Zofran 4mg IVP 10/4/2024 at 8:28AM. R1's Physician Progress note dated 10/6/2024 documents Chief Complaint: Acute Dehydration, Hydronephrosis, and Hematoma of breast. Documents patient is uncomfortable when turning or getting cleaned up. Moans often. Doesn't converse. Significant bruising noted across chest. Hematoma/tense area of left breast. Provider documented as V18. R1's Discharge summary dated [DATE] include admission diagnoses of Chest Wall Hematoma, Severe right sided Hydronephrosis, history of Deep Vein Thrombosis, Hypertension, Hyperlipidemia. Discharge diagnoses include, Chest wall hematoma (unknown etiology), Severe right sided hydronephrosis, hypoglycemia, low bicarb, history of deep vein thrombosis, hypertension, hyperlipidemia, right foot wound, and Alzheimer's disease. Document includes Primary Care Physician as V19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 6 of 11 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 10/17/2024 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few R1's Progress notes dated 10/7/2024 documents Sodium remains low despite fluids; Hemoglobin continues to trend down. Continue to hold Eliquis. Pain Control. Referral to a different Long Term Care facility. Patient not eating or drinking and recommended hospice at this time. R1's Discharge Summary dated 10/9/2024 documents R1 discharged to a different Long Term Care facility under hospice care. Prescriptions sent for Morphine and Ativan. Documented Acute Posthemorrhagic Anemia. Document signed by V20. On 10/9/2024 reviewed photos taken in the emergency room on [DATE], R1's left lateral chest area with noted bruising with non-bruised line in between bruising. Bruising to this area was noted to be red in color. Photo of Chest show dark red/purple bruising to the left breast, the left breast has edema noted, under the left breast and discoloration up to the anterior axilla area and down left inner aspect of left arm. Bruising noted to the middle of the chest as well. Bruising dark red / purple bruising noted right side of Chest area involving the right breast, under the right breast into the abdominal area and up to the anterior part of the chest above the breast up to the top of the shoulder to the right chest. On 10/10/2024 at 11:00 AM, V23 (Certified Nurse Assistant/CNA) stated she was working the morning of 10/4/2024 and saw the bruising on R1's breast. V23 stated she left her in bed and went to get the nurse because R1 was in so much pain we could not even touch her. V23 stated the nurse got the DON and then the resident was sent out to the hospital. V23 was asked how she normally transferred her, and she stated, we always use 2 people and we each get under her arm and under her knee and move her that way. V23 stated this is the safest way to transfer the resident. V23 stated she doesn't use a gait belt very often while transferring residents. On 10/9/2024 at 11:16 AM, V12 (CNA) was asked if he cared for R1 on 10/3/2024 or 10/4/2024. V12 stated he did not care for R1 on 10/3/2024 but came in on 10/4/2024 and saw all the bruising and reported to the nurse. V12 stated he was told the bruising was found on 10/3/2024 on the evening shift. V12 stated R1 was in severe pain and couldn't hardly tolerate being touched. V12 stated he did not know how the bruising happened. V12 was asked how he transferred R1 to the bed or wheelchair. V12 stated, I always do the arm and arm transfer with her by myself. V12 stated like a bear hug, he places his arms under R1's arms and they are facing each other, and he lifts and turns to place her in the bed or in the wheelchair. V12 stated it really depends on how busy we are too. V12 was asked if he has a gait belt available and he stated , Not on me. I have one probably in my car. V12 was asked why he does not use a gait belt to transfer R1 and V12 stated, I usually don't have time, nor do we have the staff to take the time and do that. V12 was asked if he had gait belt training and he stated, The last time was in CNA class, and I have not had any training here. V12 stated on the morning of 10/4/2024, I know R1 was crying in pain, and it did look really bad. On 10/10/2024 at 10:30 AM, V12 stated he was working the morning R1 was transferred out and R1 was in horrible pain and could not stand to be touched. V12 stated he helped transfer R1 to the stretcher with EMS (Emergency Medical Services) and they had to use a draw sheet to move her because of the pain. V12 stated he explained to the medics how the resident is normally transferred, and he explained that he uses the bear hug technique when he puts his arms under her arms and lifts, and she puts her arms around him like a hug and then he lifts and turns. On 10/10/2024 at 10:50 AM, V25 (CNA) stated she laid R1 down on 1/3/3034 after lunch and she used a gait belt. V25 stated, I usually get someone to help but I can safely transfer her by myself. V25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 7 of 11 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 10/17/2024 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)

F 0689 stated she didn't remove R1's sweater and she did not notice any type of bruising and R1 did not complain of any pain. Level of Harm - Actual harm Residents Affected - Few On 10/10/2024 at 5:27 PM, V26 (Registered Nurse/RN) stated he was working on 10/3/2024 when he was summoned to the shower room to look at R1's left breast. V26 stated R1's left breast was swollen and had some bruising and slight bruising under the left arm. V26 stated he palpated the left breast and R1 didn't show signs of pain. V26 stated he felt the bruising was all superficial and it wasn't a big concern because the resident was on Eliquis. V26 stated he checked on R1 throughout the night by peeking in her room and R1 was resting in bed with no signs of pain or discomfort. V26 stated he last checked on R1 around 4;30AM and she was resting. V26 stated he notified the MD and DON early morning on the 4th and could not reach the family. On 10/10/2024 at 5:41 PM, V27 (CNA) stated, I went to get R1 up for a shower after supper and she was sitting in her room in her wheelchair, so I took the shower chair back to the shower room and went back and pushed R1 in her wheelchair to the shower room. I asked V24 to help with the transfer as the shower chair is higher than the wheelchair. V27 stated the transfer went fine but no gait belt was used. V27 stated, I then started undressing R1 and that is when I saw the bruising. V27 stated, I had gotten R1 up for supper, but she still had on a sweater, and I did not see her chest or any upper body parts. V27 stated, I transfer R1 usually by myself and I have her to hug me, and I wrap my arms around R1 under her arms and pull the back of her pants and turn. V27 stated it is a smooth transfer. V27 stated, I asked someone to get the nurse when I saw the bruises and I got clearance from the nurse to complete the shower and so I completed the shower and put the resident to bed. V27 stated there were no complaints of pain at that time. V27 stated the grand daughter had been there during supper meal and pushed R1 back to her room but did not put her to bed. On 10/10/2024 at 6:10 PM, V28 (CNA) stated she worked on 10/3/2024 but she did not get R1 out of bed for supper. V28 stated she was in the shower giving another resident a shower when she heard another CNA state come her and look at this bruise on R1. V28 stated she went over and looked at the bruise on R1's left breast. V28 stated it was bad and it was swollen. V28 stated her breast were lop sided. V28 stated the nurse came into the shower room and looked at the breast and said to continue shower and then they took her to bed. V28 stated when she does transfer R1 she always has someone help her and they lift under the arms. V28 stated, We never use a gait belt. On 10/10/2024 11:40 AM, V24 (CNA) stated she was working the night of 10/3/2024 when the bruise to R1's left breast was noted. V24 stated she was summoned to the shower room to help with transfer to shower chair. As R1 was being undressed she and the other CNA noticed the bruise to the left breast and called for the nurse. V24 stated she never uses a gait belt when transferring residents. V24 stated when she transfers R1 she always gets help because she is fragile. On 10/15/2024 at 9:54 AM, V29 (ER/Physician) stated he took care of R1 while she was in the ER. V29 stated there was much bleeding noted with the bruising and the hematoma to the left breast. V29 stated R1 was in bad pain, and it was controlled with IV (Intravenous) medications. V29 stated R1 mostly laid in the fetal position on her right side with her hands over her face. V29 stated he is not sure what happened, and he could not say if the bruising was from a traumatic or non-traumatic injury. V29 stated with R1 being on Eliquis, the bleeding and bruising was probably worsened due to the blood thinner. 2. R2's admission Record includes admission date of 9/11/2024 and diagnoses of ST Elevation Stemi (ST-segment Elevation Myocardial Infarction), Pneumonitis, Atherosclerotic Heart Disease, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 8 of 11 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 10/17/2024 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)

F 0689 Aortocoronary Bypass Graft, Dependence of Supplemental Oxygen. Level of Harm - Actual harm R2's MDS (Minimum Data Set) dated 9/18/2024 includes a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. Section GG Functional Abilities and Goals document R2 requires partial/moderate assistance with toileting, shower, upper body dressing and lower body dressing. R2 requires supervision/or touching assistance with car transfer, walking 10 feet, 50 feet, and 150 feet, transferring to toilet, sit to stand. Residents Affected - Few R2's Care plan documents R2 is a potential risk for falls and injury due to shortness of breath, weakness, pain, hypertension, hard of hearing, confusion, diabetes, oxygen dependence. Care plan documents on 10/3/2024 at 1630 (4:30pm) with Fall transport van (minor injury) revision date 10/8/2024. R2's Witnessed Fall Report dated 10/3/2024 at 4:30 PM documents, Incident location: out of facility/during transport and person preparing report is V8 (DON). Incident description: On 10/4/2024 at approximately 9:30 AM it was reported to DON that resident was stating that while she was being transported back to facility via transport van that her wheelchair tipped all the way over backwards. This was not reported to nursing staff that she had a fall in van. R2 stated My chair tipped over backwards; girl lifted me back up. Immediate action taken: After speaking to CNA/transport driver (V5) she stated that yes, her wheelchair tipped all way over backwards when she hit her breaks. Floor nurse was notified of resident's statement that she had fallen in wheelchair yesterday. She was assessed by nurse immediately after being informed, noted bruise to back of shoulder, no swelling, did complain pain at site. MD (Medical Doctor) notified for x-ray, obtained. Documents MD notified on 10/4/2024 at 10:00AM and Family member notified on 10/4/2024 at 2:00PM. Written statement signed by V5 documents incident occurred on 10/3/2024 at approximately 3:30PM. Incident described in written document including R2 did complain that her shoulder hurt, and she checked her shoulder to see if anything was wrong with it, there was nothing wrong. Document also includes documentation of Did not report incident to the nurse. On 10/9/2024 at 10:20 AM, R2 was being transferred into bed with assistance of V3 (Certified Occupational Therapy Assistant/ COTA) using a gait belt. R2 was asked if she had any pain anywhere and R2 stated my shoulder is a little sore and a little bruised. R2 stated she fell back and sideways in her wheelchair while in the van coming back from a doctor's appointment. R2 stated, 'they didn't strap me down very good. R2 stated, I told my daughter when she came to visit, and she didn't know anything about it. R2 stated then the nurses came and checked her out and then she had an x-ray of her shoulder. R2 stated V3 came in the room when her daughter was there visiting, and my daughter told her about it. On 10/9/2024 at 10:24AM, V3 COTA stated she came in the room on 10/4/2024 and the daughter was in the room and R2 had told her about the incident in the van. V3 then stated she reported it as well. V3 stated the shoulder has not affected R2's therapy at all. V3 stated R2 doesn't complain of pain to her during therapy. On 10/9/2024 at 10:00AM observed R2 in room with light colored old bruising noted to back of right shoulder. On 10/10/2024 at 1:00PM, V1 stated she had never been told there was an issue with the van or with the red light not functioning properly. V1 stated V5 did not report to any staff upon return with R2, that an incident occurred. V1 stated V5 was terminated because of not reporting the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 9 of 11 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 10/17/2024 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few On 10/9/2024 at 1:38PM, V5 (Transportation/CNA) stated she had strapped R2 in the back with the straps in place. V5 stated as she was pulling out from a stop light the wheelchair flipped back and the resident stayed in the wheelchair and fell backwards. V5 stated she was on the interstate, so she had to pull off and help the resident back into the wheelchair. V5 stated R2 denied any pain or injuries. V5 stated when she returned to the facility, she took R2 to her room and helped her into bed. V5 stated she forgot to tell anyone about the incident. V5 stated the next day she told the Administrator, Director of Nursing and Maintenance that the red light on the white van was not working properly to let you know if the wheelchair is secure. V5 stated she was terminated for not reporting the incident when she returned to the facility. R2's Progress Notes dated 10/4/2024 at 9:07 AM documents R2 complained of right shoulder pain, Oxycodone HCL 5mg (milligram) tablet given. Note dated 10/4/2024 at 11:16 AM documents R2 complained of right shoulder pain, MD (Medical Doctor) notified, orders for mobile x-ray. Family at bedside and notified. Note dated 10/6/2024 at 12:18PM documents X-ray results received noting no fracture or dislocation. Family notified. 3. R3's admission Record includes an admission date of 9/21/2023 and includes diagnoses of Acute Kidney Failure, Repeated Falls, Anemia, Major Depressive Disorder, Muscle weakness Type 2 Diabetes Mellitus, Hypertension. R3's MDS (Minimum Data Set) dated 10/1/2024 includes a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. Section GG documents R3 uses a manual wheelchair, R3 requires supervision with toileting hygiene, partial to moderate assist with shower/bathing, lower body dressing, and putting on/taking off footwear. R3 requires set up assistance with eating, oral hygiene, and upper body dressing. Partial/moderate assistance with sit to stand, chair/bed-to chair transfer, shower transfer, and walking. R3 is independent with wheelchair mobility. R3's Care plan documents Focus R3 is at risk for falls and injury, Interventions supervise resident and assist appropriately with transfers with revision date of 9/21/2023. On 10/9/2024 at 1:15PM, R3 stated when the staff help her to and from bed, they do not use any type of belt for transfers. R3 stated they just get my arms and help me. R3 stated she has not had any injuries from transfers. On 10/10/2024 at 1:00PM observed V7 (CNA) and V25 (CNA) transfer R3 from wheelchair to bed with assist of 2 and the proper use of a gait belt. No concerns noted. At that time R3 stated What is that thing you are putting around me, are you going to hang me or something. 4. R11's admission Information documents admission date of 9/30/2024 with diagnoses of Nondisplaced fracture of right Femur, Severe Protein-Calorie Malnutrition, Heart Failure, Anxiety Disorder, Chronic Kidney Disease stage 3. R11's MDS (Minimum Data Set) dated 10/9/2024 includes a BIMS (Brief Interview for Mental Status) score of 10 indicating moderate cognitive impairment. Section GG documents R11 requires Partial/moderate assistance with Shower/bathing, toileting hygiene, upper body dressing, lower body dressing, putting on/off footwear, and personal hygiene. R11 also requires Partial/moderate assistance with sit to stand position, chair/bed transfer. On 10/9/2024 at 1:50PM observed V6 (Licensed Practical Nurse) transfer R11 from wheelchair to bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 10 of 11 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 10/17/2024 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)

F 0689 with no gait belt. Level of Harm - Actual harm Facility's Policy and Procedure for Gait Belt Use undated, documents in part, Always use a Gait Belt unless it is contraindicated: A) Bone cancer involving the spine. B) Fractured ribs. C) Over an ostomy. D) Over an open healing incision. E) If it causes pain or fear. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145386 If continuation sheet Page 11 of 11