Southgate Health Care Center

In the surveyor’s words

From the most serious findings on record at Southgate Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF697Mar 27, 2026

  Based on observations, interviews, and record reviews, the facility failed to provide effective pain management for 3 of 3 residents (R1, R2, and R3) reviewed for pain in a sample of 4. This failure resulted in R1, who has a diagnosis of Multiple Myeloma and at the end-of-life stage, not receiving an ordered narcotic pain medication for 6 hours and R1 experiencing intense pain and suffering prior to her death.This failure resulted in Immediate jeopardy, which was identified to have begun on [DATE] when the facility ran out of R1's oral Dilaudid pain medication resulting in R1 experiencing uncontrolled pain. V1 (Administrator), V21 (Regional Clinical Coordinator), V2 (Director of Nursing, and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 2:10PM. […]

• Immediate jeopardy, isolatedF684Apr 14, 2023

  Based on observation, interview, and record review, the facility failed to recognize the urgency of a worsening wound and seek immediate evaluation and treatment after noting a significant change in the condition of the wound for 1 (R38) of 7 residents reviewed for wound care in a sample of 77. This failure resulted in R38 developing gas gangrene with underlying osteomyelitis requiring emergent trans-metatarsal amputation and subsequent Chopart's (forefoot and midfoot) amputation and R38 has been placed on hospice care. The Immediate Jeopardy began on [DATE] when R38 was observed to have a significant change to an existing necrotic wound of the left 2nd toe. […]

• Immediate jeopardy, isolatedF684Apr 6, 2021

  Based on interview and record review the facility failed to reschedule/obtain a follow-up appointment to timely address a post-surgical wound, communicate with the surgeon, evaluate/treat the wound, and seek medical treatment for 1 of 4 residents (R3) reviewed for wounds in the sample of 4. These failures resulted in an immediate jeopardy, which was identified to have begun on 2/16/21 when the facility failed to recognize that R3's post-surgical follow-up appointment was canceled without rescheduling, and without communicating with the surgeon to obtain interim instructions for wound care for over 6 weeks, resulting in a hospitalization , another surgery, hardware removal with infection in the screw holes, damage to the bone, a deep right lateral wound infection with [CONDITION(S)] and… […]

• Actual harm, isolatedF689Oct 17, 2024

  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 admitted [DATE] 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. […]

• Actual harm, isolatedF692Sep 26, 2024

  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. a 14% weight loss in less than 3 months. Findings include: R3's Admission Record documents an admitted [DATE] 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. […]