F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based 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.Findings include:On 1/20/26 at 1:35 PM, a digital metal stemmed thermometer used for taking
temperatures for this survey was checked for accuracy using the ice-point method and was accurate within
+/- 2 degrees Fahrenheit.On 1/20/26 at 1:50 PM, the hot water temperature taken with a calibrated digital
metal stemmed thermometer was taken at the hand sink of the A hall shower room registered 121.4
degrees Fahrenheit (F). At that time the A hall hot water heater mixing valve was set at 104 degrees
Fahrenheit.On 1/20/26 at 2:18 PM, the hot water temperature taken with a calibrated digital metal stemmed
thermometer was taken at the hand sink of the 200-hall shower room registered 128.0 degrees F and
slowly dropped below 110 degrees F after approximately one minute. At that time the 200-hall hot water
heater mixing valve was set at 126 degrees F.On 1/20/26 at 2:37 PM, the hot water temperature taken with
a calibrated digital metal stemmed thermometer was taken at the hand sink of the B hall shower room
registered 119.6 degrees F. At that time the B hall hot water heater mixing valve did not have a gauge
present so the temperature it was set to was unable to be determined. V8 (Maintenance Director) said the
B hall mixing valve was the old style and only had a knob with the temperatures documented on it to know
what temperature the mixing valve was set at. V8 said the knob had broken off the mixing valve so there
was no way to know what the temperature was set at.On 1/20/26 at 3:02 PM, the hot water temperature
taken with a calibrated digital metal stemmed thermometer was taken at the hand sink of a R10, R11 and
R12's personal bathroom on 200 hall registered 120.7 degrees F.On 1/20/26 at 3:35 PM, V1 (Administrator)
said she was going to call corporate and get someone to the facility to look at the hot water heaters as soon
as possible. V1 said no residents had been burned due to the hot water.On 1/22/26 at 12:43 PM, V8
(Plumber) said he had been to the facility to assess the hot water heaters. V8 said B hall and 200 hall's hot
water heater's recirculation pumps had been incorrectly plumbed. V8 said due to the way the recirculation
pumps had been put in the mixing valves were irrelevant to the water temperatures because the
recirculation pumps bypassed the mixing valves causing the temperature to be too high. V8 said the mixing
valve on B hall was not working at all. V8 said he had turned B hall's mixing valve all the way down then
turned it all the way up and the water temperature had not changed.On 1/20/26 at 2:11 PM, V8 said he
completed hot water temperature checks weekly and kept the log in his office.The facility's Weekly Water
Temperature Log documented hot water temperatures were checked on all the halls on 1/2/26, 1/9/26, and
1/16/26 with none being higher than 110 F.On 1/20/26 at 3:45 PM, V1 (Administrator) presented a 1/19/26
Daily Census with Confused and ambulatory or w/c (wheelchair) written at the bottom of the page. V1
highlighted 45 of the 90 residents residing as the facility to indicate those residents were confused and
ambulatory. On this list R10 and R12 were noted to be confused and
(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 8
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
01/27/2026
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 - Minimal harm
or potential for actual harm
ambulatory. This census sheet also documents R10, R11 and R12 reside in rooms next to each other that
have a shared bathroom.On 1/23/26 at 12:47 PM, V1 stated the facility did not have a hot water
temperature policy.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145386
If continuation sheet
Page 2 of 8
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
01/27/2026
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based 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.Findings include: On 1/16/26 at 11:16 AM, V1 (Administrator) presented surveillance footage from
the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified Nursing Assistant/ CNA) is
observed pulling the keys to the medication cart and the medication room out of her pocket, opening the
medication cart, popping medications into medication cups, taking the medication cups to resident rooms
for administration, and opening the medication room door without a nurse present. V5 is observed to be
documenting medications administered on a facility laptop computer. V1 said V5 did not have a log in for the
Electronic Medical Record (EMR) and was unsure how V5 was documenting the medications.On 1/16/26 at
12:24 PM, V1 presented video surveillance footage of 1/15/26 with the time stamps as follows: 9:04 PM
showing V5 taking a cup of medications to R1's room, 9:11 PM V5 taking a cup of medications to R2's
room, 9:46 PM V5 taking a cup of medication to R3's room. V1 said V5 was supposed to be working with
another nurse and should not have been administering medications to residents.1.R1's Administration
Record documented an admission date of 8/18/25 with anemia, atrial flutter, and hypertension. R1's 1/9/26
Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1
was cognitively intact.R1's January 2026 Medication Administration Record (MAR) documented on 1/15/26
at 2000 (8:00 PM) V7 (Licensed Practical Nurse/ LPN) had administered Atorvastatin 40 mg, Melatonin 2
mg, Tamsulosin 0.4 mg, Iron Sulfate 325 mg, Metformin 250 mg, and Protonix 20 mg. On 1/16/26 at 9:45
AM, R1 said V5 brought him his medications the evening of 1/15/26 and R1 did not see another nurse with
V5. R1 said he did not know V5's name but it was the dark-haired girl that had previously been a CNA in
the facility. R1 said V5 had finished her courses and now she in a nurse. R1 said V5 was now working
independently.2. R3's admission Record documented an admission date of 8/14/24 with diagnoses
including chronic obstructive pulmonary disease, type 2 diabetes, and fibromyalgia. R3's 12/13/25 MDS
documented a BIMS score of 15, indicating R3 was cognitively intact.R3's January 2026 MAR documented
on 1/15/26 at 2000 (8:00 PM) V7 had administered Hydrocodone/ Acetaminophen 3/325 mg 2 tablets,
Olanzapine 2.5 mg, Rosuvastatin 40 mg, Docusate sodium 100 mg, Lactulose 10 mg/ 15 ml 15 ml,
Lamictal 100 mg, Oxcarbazepine 150 mg, Potassium 20 meq, and Reglan 5 mg.On 1/16/26 at 9:25 AM, R3
said she believed V5 had brought her medications to her on the night of 1/15/26. R3 said V5 had been
working with another nurse previously but hadn't been lately. R3 said she did not see another nurse with
V5, the only other people she saw were the CNAs when V5 brought R3 her medications.3. R4's
Administration Record documented an admission date of 8/18/25 with diagnoses including type 2 diabetes,
hyperlipidemia, and spinal stenosis. R4's 11/25/25 MDS documented a BIMS score of 15, indicating R4
was cognitively intact.R4's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM) V7 had
administered Simvastatin 20 mg, Depakote 250 mg, Depakote 500 mg, Docusate sodium 100 mg,
Acetaminophen 650 mg, and Gabapentin 400 mg.On 1/16/26 at 9:31 AM, R4 said the new girl (V5) gave
me my medications last night. R4 said he did not see V5 working with another nurse on 1/15/26.4. R2's
admission Record documented an admission date of 6/3/21 with diagnoses including osteomyelitis,
vasculitis, and chronic pain syndrome.R2's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM)
V7 had administered Trazodone 50 mg, Cephalexin 500 mg, Memantine 5 mg, Sennosides-Socusate
sodium 8.6- 50 mg, MS Contin 15 mg, and Pregabalin 200 mg.On 1/16/26 at 10:49 AM, V5 said she did not
work independently on 1/15/26 and V7 had been present while V5 was administering medications to
residents. V5 said she did hold the keys to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145386
If continuation sheet
Page 3 of 8
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
01/27/2026
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
medication cart and medication room. V5 said she and V7 set up the resident medication cups at the
medication cart in front of the nurse's station and V5 took the medications to the residents. V5 said V7 did
not accompany V5 to the resident rooms. V5 was asked if she completed any of the charting in resident's
EMRs and V5 said she did not because she did not have a log in for the EMR.On 1/20/26 at 10:19 AM, V7
said she had given V5 her EMR log in and V5 had taken the computer. V7 said she was not present while
V5 was administering medications to residents. V7 said it was not typical for V7 to give her EMR log in to
other employees to document under her name, but V7 trusted V5. V7 said if it had been another person
other than V5 V7 probably wouldn't have given them her log in information.On 1/16/26 at 11:55 AM, V2
(Director of Nursing/ DON) said she expected another nurse to be present when V5 was administering
medications to residents and V2 had told V5 she could not administer medications to residents. V2
confirmed that V5 was not a licensed nurse. V2 said she would not expect a nurse to give their EMR log in
to another employee to document in resident's EMRs. V2 said the nurse administering the medications
should be the person documenting it in the resident's EMR. The facility's revised May 27, 2025
Administering Medications policy documented in part . 1. Only persons licensed or permitted be this state to
prepare, administer, and document the administration of medications may do so. 22. The individual
administering the medication initials the resident's MAR on the appropriate line after giving each medication
and before administering the next ones.The facility's revised November 2022 Documentation of Medication
Administration policy documented in part . 1. A nurse or certified aide (where applicable) documents all
medications administered to each resident on the resident's medication administration record (MAR). 3.
Documentation of medication administration includes, as a minimum: g. initials, signature and title of the
person administering the medications.The facility's 10/25/25 Job Description and Duties for the Job Title:
Charge Nurse (LPN or RN) documented in part . The LPN and RN provide and oversees nursing care on
their assigned unit/ hall. The LPN an RN ensure care is delivered according to resident care plans,
administers medications and treatments, and monitors residents for changes in condition. The LPN and RN
ensure compliance with the Department of Public Health and CMS regulations, maintains accurate
documentation, and supports a safe, compassionate, and resident-centered environment. Key
Responsibilities: 3. Accurately administer and document medications and treatments in compliance with
facility policy, CMS and state regulations. 8. Maintain clear and timey documentation in the electronic
medical record (EMR) per facility and regulatory standards. 18. Initials medication/ treatment administration
records accordingly.The facility's 1/16/26 Daily Census documented 91 residents residing in the facility.
Event ID:
Facility ID:
145386
If continuation sheet
Page 4 of 8
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
01/27/2026
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based 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. Findings include:On 1/16/26 at 11:16 AM, V1 (Administrator) presented
surveillance footage from the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified
Nursing Assistant/ CNA) is observed pulling the keys to the medication cart and the medication room out of
her pocket, opening the medication cart, popping medications into medication cups, taking the medication
cups to resident rooms for administration, opening the schedule II controlled medication box, popping
schedule II medications into medication cups, signing out schedule II medications in the schedule II count
binder, and opening the medication room door without a nurse present.On 1/16/26 at 12:24 PM, V1
presented video surveillance footage of 1/15/26 with the time stamps as follows: 9:04 PM showing V5
taking a cup of medications to R1's room, 9:11 PM V5 taking a cup of medications to R2's room, 9:46 PM
V5 taking a cup of medication to R3's room. V1 said V5 was supposed to be working with another nurse
and should not have been administering medications to residents.R1's Administration Record documented
an admission date of 8/18/25 with anemia, atrial flutter, and hypertension. R1's 1/9/26 Minimum Data Set
(MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively
intact.1. R1's January 2026 Medication Administration Record (MAR) documented on 1/15/26 at 2000 (8:00
PM) V7 (Licensed Practical Nurse/ LPN) had administered Atorvastatin 40 mg, Melatonin 2 mg, Tamsulosin
0.4 mg, Iron Sulfate 325 mg, Metformin 250 mg, and Protonix 20 mg. On 1/16/26 at 9:45 AM, R1 said V5
brought him his medications the evening of 1/15/26 and R1 did not see another nurse with V5. R1 said he
did not know V5's name but it was the dark-haired girl that had previously been a CNA in the facility. R1
said V5 had finished her courses and now she in a nurse. R1 said V5 was now working independently.R3's
admission Record documented an admission date of 8/14/24 with diagnoses including chronic obstructive
pulmonary disease, type 2 diabetes, and fibromyalgia.R3's 12/13/25 MDS documented a BIMS score of 15,
indicating R3 was cognitively intact.R3's January 2026 MAR documented on 1/15/26 at 2000 (8:00 PM) V7
had administered Hydrocodone/ Acetaminophen 5/325 mg 2 tablets, Olanzapine 2.5 mg, Rosuvastatin 40
mg, Docusate sodium 100 mg, Lactulose 10 mg/ 15 ml 15 ml, Lamictal 100 mg, Oxcarbazepine 150 mg,
Potassium 20 meq, and Reglan 5 mg.R3's hydrocodone/ Acetaminophen 5/325 mg tablet Controlled Drug
Record documented on 1/15/26 at 2005 (8:05 PM ) 2 tablets was removed from the count with V5 and V7's
signature.On 1/16/26 at 9:25 AM, R3 said she believed V5 had brought her medications to her on the night
of 1/15/26. R3 said V5 had been working with another nurse previously but hadn't been lately. R3 said she
did not see another nurse with V5, the only other people she saw were the CNAs when V5 brought R3 her
medications.3. R4's Administration Record documented an admission date of 8/18/25 with diagnoses
including type 2 diabetes, hyperlipidemia, and spinal stenosis. R4's 11/25/25 MDS documented a BIMS
score of 15, indicating R4 was cognitively intact.R4's January 2026 MAR documented on 1/15/26 at 2000
(8:00 PM) V7 had administered Simvastatin 20 mg, Depakote 250 mg, Depakote 500 mg, Docusate sodium
100 mg, Acetaminophen 650 mg, and Gabapentin 400 mg.On 1/16/26 at 9:31 AM, R4 said the new girl
(V5) gave me my medications last night. R4 said he did not see V5 working with another nurse on
1/15/26.4. R2's admission Record documented an admission date of 6/3/21 with diagnoses including
osteomyelitis, vasculitis, and chronic pain syndrome.R2's January 2026 MAR documented on 1/15/26 at
2000 (8:00 PM) V7 had administered Trazodone 50 mg, Cephalexin 500 mg, Memantine 5 mg,
Sennosides-Socusate sodium 8.6- 50 mg, MS Contin 15 mg, and Pregabalin
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145386
If continuation sheet
Page 5 of 8
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
01/27/2026
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
200 mg.R2's Pregabalin 200 mg capsule Controlled Drug Record documented on 1/15/26 at 1920 (7:20
PM ) 1 capsule was removed from the count with V5 and V7's signature.On 1/16/26 at 10:49 AM, V5
(Certified Nursing Assistant/ CNA) said she did hold the keys to the medication cart and the medication
room on 1/15/26. V5 said while administering medications to residents on 1/15/26 V7 (Licensed Practical
Nurse/ LPN) had been present. V5 said she and V7 had both signed the schedule II medications out in the
schedule II count binder.On 1/20/26 at 10:19 AM, V7 said she had not been present when V5 was
administering medications to residents on 1/15/26. V7 said she signed the schedule II medication count
binder at the end of the shift when V7 and V5 counted the schedule II medications, but had not been
present when V5 was administering schedule II medications to residents on 1/15/26. On 1/16/26 at 11:55
AM, V2 (Director of Nursing/ DON) said she expected the medication cart and medication room keys were
only to be accessible to licensed nurses and V5 was not a licensed nurse. V2 said unlicensed individuals
should not have access to any medications or schedule II-controlled medications.The facility's revised
November 2022 Controlled Substances policy documented in part . The facility complies with all laws,
regulations, and other requirements to handling, storage, disposal, and documentation of controlled
medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of
1976) .Handling Controlled Substances. 1. Only authorized licensed nursing and/or pharmacy personnel
have access to Schedule II controlled substance maintained on premises. Storing Controlled Substances.
2. All keys to controlled substance containers are on a single key ring that is different from any other keys.
3. The charge nurse on duty maintains the keys to controlled substance containers.The facility's 10/25/25
Job Description and Duties for the Job Title: Charge Nurse (LPN or RN) documented in part . The LPN and
RN provide and oversees nursing care on their assigned unit/ hall. The LPN an RN ensure care is delivered
according to resident care plans, administers medications and treatments, and monitors residents for
changes in condition. The LPN and RN ensure compliance with the Department of Public Health and CMS
regulations, maintains accurate documentation, and supports a safe, compassionate, and
resident-centered environment. Key Responsibilities: 20. Ensures all medications and treatments are stored
safely and appropriately.The facility's 1/16/26 Daily Census documented 91 residents residing in the facility.
Event ID:
Facility ID:
145386
If continuation sheet
Page 6 of 8
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
01/27/2026
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 0839
Employ staff that are licensed, certified, or registered in accordance with state laws.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.Findings include:On 1/16/26 at 11:16 AM, V1 (Administrator) presented
surveillance footage from the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified
Nursing Assistant/ CNA) is observed pulling the keys to the medication cart and the medication room out of
her pocket, opening the medication cart, popping medications into medication cups, taking the medication
cups to resident rooms for administration, opening the schedule II controlled medication box, popping
schedule II medications into medication cups, signing out schedule II medications in the schedule II count
binder, and opening the medication room door without a nurse present.On 1/16/26 at 12:24 PM, V1
presented video surveillance footage of 1/15/26 with the time stamps as follows: 9:04 PM showing V5
taking a cup of medications to R1's room, 9:11 PM V5 taking a cup of medications to R2's room, 9:46 PM
V5 taking a cup of medications to R3's room. V1 said V5 was supposed to be working with another nurse
and should not have been administering medications to residents.On 1/16/26 at 9:45 AM, R1 said V5
brought him his medications the evening of 1/15/26 and R1 did not see another nurse with V5. R1 said he
did not know V5's name but it was the dark-haired girl that had previously been a CNA in the facility. R1
said V5 had finished her courses and now she in a nurse. R1 said V5 was now working independently. R1's
1/9/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15,
indicating R1 was cognitively intact.On 1/16/26 at 9:25 AM, R3 said she believed V5 had brought her
medications to her on the night of 1/15/26. R3 said V5 had been working with another nurse previously but
hadn't been lately. R3 said she did not see another nurse with V5, the only other people she saw were the
CNAs when V5 brought R3 her medications. R3's 12/13/25 MDS documented a BIMS score of 15,
indicating R3 was cognitively intact.On 1/16/26 at 9:31 AM, R4 said the new girl (V5) gave me my
medications last night. R4 said he did not see V5 working with another nurse on 1/15/26. R4's 11/25/25
MDS documented a BIMS score of 15, indicating R4 was cognitively intact.On 1/16/26 at 10:49 AM, V5
(CNA) said she finished the LPN (Licensed Practical Nurse) program on 12/15/25 and was scheduled to sit
for boards on 1/23/26. V5 said she was working as LPN License Pending in the facility. V5 said she was not
supposed to be working independently and was supposed to be shadowing another nurse.On 1/20/26 at
10:19 AM, V7 (LPN) said she had not been present on 1/15/26 when V5 was administering resident
medications. V7 said V5 had been working independently as a licensed nurse in the facility for about a
week prior to this survey. V7 said she had been told V5 was working on a provisional license and could
work as a licensed nurse independently. On 1/16/26 at 11:55 AM, V2 (Director of Nursing/ DON) said V5
was working in the facility as a Licensed Practical Nurse License Pending. V2 said License Pending means
you don't have your license yet but can work under another nurse. V2 stated you would think you would
have to sit for boards (National Council Licensure Examination/ NCLEX) before working license pending. V2
stated I know (V5) was scheduled to sit for boards but I'm not sure if (V5) has yet or not. V2 said V5 had not
presented anything to V5 indicating V5 had passed the NCLEX. V2 said V5 was supposed to be being
supervised by V7 on 1/15/26.The facility's licensed nurse schedule from 1/1/26 through 1/15/26
documented on 1/15/26 V5 was assigned a portion of the facility's resident population, and no specific
licensed nurse was assigned to oversee V5.The 2024 Illinois Nurse Practice Act documents in part .2024
Illinois Compiled StatutesChapter 225 - PROFESSIONS, OCCUPATIONS, AND BUSINESS
OPERATIONS225 ILCS 65/ - Nurse Practice Act.Article 55 - Nursing Licensure-Licensed Practical Nurses.
Sec. 55-10. LPN licensure by examination. (d) A licensed practical nurse applicant who passes the
Department-approved licensure
Residents Affected - Many
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145386
If continuation sheet
Page 7 of 8
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
01/27/2026
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 0839
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
examination and has applied to the Department for licensure may obtain employment as a license-pending
practical nurse and practice as delegated by a registered professional nurse or an advanced practice
registered nurse or physician. An individual may be employed as a license-pending practical nurse if all of
the following criteria are met: (1) He or she has completed and passed the Department-approved licensure
exam and presents to the employer the official written notification indicating successful passage of the
licensure examination. (2) He or she has completed and submitted to the Department an application for
licensure under this Section as a practical nurse. (3) He or she has submitted the required licensure fee. (4)
He or she has met all other requirements established by rule, including having submitted to a criminal
history records check.https://law.justia.com/codes/illinois/chapter-225/act-225-ilcs-65/article-55/The facility's
10/25/25 Job Description and Duties for the Job Title: Charge Nurse (LPN or RN) documented in part . The
LPN and RN provide and oversees nursing care on their assigned unit/ hall. The LPN an RN ensure care is
delivered according to resident care plans, administers medications and treatments, and monitors residents
for changes in condition. The LPN and RN ensure compliance with the Department of Public Health and
CMS regulations, maintains accurate documentation, and supports a safe, compassionate, and
resident-centered environment. Job Requirements: 1. Maintain current state nursing licensure (LPN or RN)
in good standing.The facility's 1/16/26 Daily Census documented 91 residents residing in the facility.
Event ID:
Facility ID:
145386
If continuation sheet
Page 8 of 8