Health inspection·May 30, 2025

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings include: R1's admission Record documents an admission date of [DATE] with diagnoses including Encounter for Palliative Care, Chronic Pain Syndrome, Amyotrophic Lateral Sclerosis (ALS), Anxiety, Major Depressive Disorder. Special instruction document Residential Hospice of Southern Illinois. R1's Hospice Initial Plan of Care dated [DATE] documents a start of care date of [DATE] with a Terminal Diagnosis of Amyotrophic Lateral Sclerosis (ALS). This same document is marked yes under the category of DNR (Do Not Resuscitate). R1's facility Care Plan documents a Focus area of R1's wish is to be resuscitated and CPR to be initiated if his heart stops with an initiation date of [DATE]. Interventions documented include: all staff should perform Heimlich maneuver if choking and proceed with CPR, all staff should provide CPR if R1 goes into cardiac arrest, if R1 should be hospitalized for routine tests/treatments/procedures please send copy of written CPR orders/signed POLST (Practitioner Order for Life Sustaining Treatment) with other orders, and nursing please ensure R1's chart is marked with a blue dot to indicate CPR status and obtain POLST from physician. R1's Practitioner Order for Life Sustaining Treatment (POLST) form dated [DATE] documents yes under Section A. Orders for Patient in Cardiac Arrest next to CPR. Under Section B. Orders for Patient Not in Cardiac Arrest is marked Selective Treatment: Primary goal is treating medical conditions with limited medical measures. This form is signed by V9 (Power of Attorney) and dated [DATE]. R1's Progress Note dated [DATE] at 8:42PM by V4 (Licensed Practical Nurse/LPN) documents, this nurse entered resident room at approximately 8:20PM to administer bedtime meds to resident and his roommate this nurse noted that resident was pale in color and skin was cold to the touch and resident did not appear to be breathing. No pulse detected. This nurse had CNA (Certified Nursing Assistant) to get 2nd nurse to verify. Both nurses confirmed at 8:25PM by auscultation of apical pulse for one minute. That resident had expired at 8:25PM. This nurse notified family at 8:35PM, administrator at 8:40PM, hospice at 8:38PM, and VA at 8:47. On [DATE] at 11:06AM, V4 stated she worked on [DATE] and her shift started at 6:00PM. V4 stated as she was passing her evening medications, she entered R1's room around 8:15PM-8:20PM and just glanced (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 05/30/2025 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)