The Orchards at Southgate

In the surveyor’s words

From the most serious findings on record at The Orchards at Southgate, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 31, 2024

  This citation pertains to intake MI00142163. Based on observation, interview and record review the facility failed to provide adequate supervision. On January 15, 2024, at approximately 10:30 AM, R301 a cognitively impaired resident (BIMS of 4) eloped from the facility The recorded temperature that day was 9 degrees Fahrenheit. R301 walked down beside [NAME] Rd (A four lane highway) crossed Fort St (A six lane highway) and proceeded to (Name Redacted) Co-op Apartments (approximately 1.5 miles from facility). Director of Nursing called [NAME] Police at 11:22 AM, and it was reported resident was transported to the hospital at approximately 10:38 AM. […]

• Actual harm, isolatedF686Sep 11, 2025

  Based on observation, interview and record review, the facility failed to implement interventions to prevent and promote healing of a facility acquired unstageable pressure ulcer (a severe skin injury that occurs at the heel and cannot be accurately staged because the wound base is covered by dead tissue) for one resident (R4) of three residents reviewed for pressure ulcers, resulting in the development of an unstageable heel pressure ulcer.Findings include:On 9/9/2025 at 12:13 PM, R4 was observed in bed, wearing a hospital gown, and watching TV. R4's head of bed was slightly raised, and their right heel was positioned off of the bottom of the mattress without support of heel protectors or a pillow for support. R4's right foot revealed a heel dressing with the date of 9/8/2025. […]

• Actual harm, isolatedF692Jul 19, 2023

  Based on observation, interview, and record review the facility failed to implement nutritional interventions for weight loss for one resident (R72) of four residents reviewed for nutritional parameters, resulting in a significant weight loss. Findings include: On 7/17/23 at approximately 10:28 A.M. R72 was observed in her room in bed. The resident appeared confused, thin in statue with temporal wasting (suggestive of weight loss). On 7/17/23 at 12:30 P.M. R72 was observed sleeping throughout the lunch meal without any staff assistance with eating. At 2:30 P.M.in the evening R72 was observed wandering in her wheelchair aimlessly throughout the facility. On 7/18/23 at 8:30 A.M., review of resident's Weight and Vital Summary revealed R72 had a significant weight loss in June. […]

• Actual harm, isolatedF692Apr 7, 2022

  This citation pertains to intake MI 581 Based on interview and record review the facility failed to assess, monitor, and implement interventions to prevent weight loss, affecting one resident (R27) out three residents reviewed for nutrition, resulting in the significant weight loss of a resident. Findings include: Record review of R27's medical chart revealed admission into the facility on [DATE] with Pneumonia. Record review of MDS dated [DATE], R27 had intact cognition and needed extensive assistance with most Activities of Daily Living (ADLS). Record review of nutritional care plan revealed no revisions made since 11/26/21. Record review of medical chart revealed no nutritional assessment completed by a registered dietician during resident's stay. […]

• Actual harm, isolatedF686Aug 10, 2021

  This citation pertains to intakes: MI 092 and MI 025. Based on observation, interview, and record review the facility failed to: 1) administer pressure ulcer treatments as prescribed for an existing pressure ulcer and 2) prevent new pressure ulcers from developing for one of five residents (R306) reviewed for pressure ulcers, resulting in R306's existing pressure ulcer to deteriorate and a new left heel pressure ulcer to develop. Findings include: According to the face sheet R306 admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] indicated that R306 had severe cognition impairment, was unable to make her needs known, and was totally dependent on two staff members for bed mobility and transferring. […]