Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Orchards At Southgate during CMS and state inspections, most recent first.
An LPN administered crushed oxycodone via a PEG tube to a resident with a history of stroke, DMII, pneumonia, tracheostomy, and gastrostomy, and moderate cognitive impairment, without checking tube placement or gastric residual immediately beforehand. The LPN stated they had checked earlier in the day and did not believe rechecking was needed, despite facility protocol and the DON’s statement that placement and residual must be verified before each use of the PEG tube for medications or feedings.
Surveyors observed a wound care nurse cleanse a resident’s perineal wound area, remove soiled gloves, and immediately don clean gloves to apply cream without performing hand hygiene in between, contrary to facility policy stating that gloves do not replace handwashing. The resident had multiple medical conditions, including stroke, type II DM, pneumonia, tracheostomy, and gastrostomy, and had moderate cognitive impairment per a recent MDS BIMS score. In interviews, the nurse acknowledged not performing hand hygiene, and the DON confirmed staff are expected to follow the hand hygiene policy.
A resident with stroke-related weakness, DM2, foot drop, and CKD developed a facility-acquired unstageable right heel pressure injury after the foot rested against the bed frame and footboard. Staff observed the resident in bed without heel protectors or other pressure-relief support on multiple occasions, and the TAR showed inconsistent use of heel protectors with the devices not available in the room on several days. The care plan lacked resident-specific skin interventions, and the wound care nurse and wound physician both noted the heel wound and the need for pressure relief measures.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions, as observed in the care planning documentation.
The facility failed to maintain a safe and sanitary environment for 80 residents and staff, with cracked floor tiles, unsecured razors, and unlabeled chemicals observed. The Maintenance Director was unsure about repair responsibilities and acknowledged the need for labeling and cleaning.
The facility's kitchen failed to maintain sanitary conditions, with sanitizer concentrations at zero and improper ceiling tiles. Staff did not use hand barriers after washing, risking recontamination. Additionally, roast beef was held at temperatures below the required 135°F, indicating improper hot holding.
Two residents did not receive timely feeding assistance, leading to meals being served at potentially inappropriate temperatures. One resident was found asleep with an undisturbed tray, requiring CNA intervention, while another resident needed LPN assistance to set up and eat. Both residents had medical conditions necessitating assistance with daily activities.
A resident with Medicaid benefits did not receive necessary dental care, including tooth extractions, due to the facility's failure to follow up on a dental recommendation. The resident, who had visible broken and decayed teeth, experienced tooth pain and difficulty eating. Despite Medicaid acceptance, no dental appointment was made, likely due to the departure of the responsible social worker.
Failure to Verify PEG Tube Placement and Residual Before Medication Administration
Penalty
Summary
A deficiency occurred when an LPN administered crushed oxycodone 5 mg via PEG tube to resident R402 without verifying tube placement or assessing gastric residual immediately prior to medication administration, contrary to facility protocol. On observation, the LPN was seen at 3:55 PM giving the medication through the PEG tube without checking placement or residual, later explaining in interview that these checks had been done earlier in the day and were believed not to require repetition. The DON stated in interview that facility practice requires tube placement and residual to be checked every time before using the PEG tube for medications or feedings. Record review showed that R402 had been admitted with diagnoses including cerebral infarction (stroke), type II diabetes mellitus, pneumonia, tracheostomy, gastrostomy, and adjustment disorder with depression, and had a BIMS score of 12/15 indicating moderate cognitive impairment. Facility documentation titled “Medication VIA Gastrostomy Tube” indicated that tube placement should be checked via auscultation or aspiration. The surveyor determined that this failure resulted in the potential for aspiration and respiratory compromise for R402.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when a wound care nurse failed to perform hand hygiene between glove changes during wound-related care. During an observation, the wound care nurse cleansed a resident’s perineal wound area, removed soiled gloves, then immediately donned a clean pair of gloves and applied cream to the perineal area without performing handwashing or using an alcohol-based hand rub. In a subsequent interview, the wound care nurse acknowledged not performing hand hygiene after removing the soiled gloves and before putting on clean gloves to continue the wound care. The resident involved had been admitted with multiple diagnoses, including cerebral infarction (stroke), type II diabetes mellitus, pneumonia, tracheostomy, gastrostomy, and adjustment disorder with depression. A recent MDS assessment documented a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The DON stated that staff are expected to follow facility policy and perform hand hygiene when providing care and noted the facility’s hand hygiene policy states that hand hygiene is the single most important means of preventing the spread of infections and that the use of gloves does not replace handwashing.
Failure to Prevent and Heal a Facility-Acquired Heel Pressure Injury
Penalty
Summary
The facility failed to implement interventions to prevent and promote healing of a facility-acquired unstageable pressure ulcer on one resident’s right heel. The resident was admitted with multiple diagnoses including cerebral infarction with right-sided weakness, type II diabetes mellitus, foot drop, and chronic kidney disease. The resident’s BIMS score was 15/15, indicating no cognitive impairment, and the MDS showed impaired lower extremities and dependence with lower body activities. The resident was also admitted with a coccyx pressure ulcer and had a Braden Scale score of 14/23, indicating moderate risk for pressure injury development. During observation, the resident was found in bed with the right heel positioned off the mattress without heel protectors or pillow support, and the resident stated the wound occurred from laying the foot on the footboard and bed frame because the mattress was not long enough. On later observations, the resident was again in bed without heel protectors, and staff documented that there were no interventions in place to promote wound healing. The wound care nurse stated the resident developed the unstageable right heel wound from resting the foot against the bed frame and footboard, and also stated that the facility extended the bed and applied a mattress spacer. When asked about heel protectors, the wound care nurse said the resident required them but they could not be found in the room. Record review showed the resident had a heel wound identified in April 2025 that progressed to an acute unstageable pressure injury. The care plan noted an unstageable pressure injury to the right heel and general skin management, but it did not describe resident-specific interventions or note noncompliance with heel protectors or wound care. The treatment administration record documented that the resident refused heel protectors on one shift and that they were applied on later shifts, but the heel protectors were not available in the room on multiple days. The wound physician stated the wound was improving after debridement and that padding might have helped relieve pressure. The DON stated nursing staff should follow physician orders and policy to prevent wounds.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover the resident's assessed needs.
Environmental Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for its 80 residents and staff, leading to an increased potential for harm. During an environmental tour, surveyors observed cracked and damaged floor tiles with missing pieces in the elevator, the first-floor soiled utility room, and the laundry room near the washing machines. Additionally, three shaving razors with their protective caps removed, a squeeze bottle of soap, and two used shaving cream containers were found on the outer rim of the second floor's shower room handwashing sink. Furthermore, two unlabeled chemical spray bottles containing yellow and purple liquids were found in the soiled holding portion of the laundry room. Interviews with the Maintenance Director, staff B, revealed uncertainty about the repair responsibilities for the elevator flooring and a lack of awareness regarding the state of the second floor's shower room. Staff B acknowledged that residents might enter the shower room unsupervised and expressed an intention to clean it. Regarding the unlabeled chemical spray bottles, staff B stated that all staff should know they need to be labeled.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. During a dietary tour, it was observed that the sanitizer concentration in a sanitizing bucket was zero, contrary to the required 200-400 ppm. The Dietary Manager admitted that the sanitizer might have been from the morning and was cloudy, indicating it was not freshly prepared. Additionally, the ceiling tiles above various kitchen areas were not uniform, with some being acoustic and others smooth, which is not compliant with the requirement for surfaces to be smooth and easily cleanable. Furthermore, multiple staff members, including dietary aides and a cook, were observed not using a hand barrier to shut off the faucet after washing their hands, despite the facility having a handwashing procedure in place. This practice contradicts the U.S. Public Health Service Food Code, which requires using a barrier to prevent recontamination. Additionally, a meal test tray revealed that roast beef was being held at temperatures between 108 and 112 degrees Fahrenheit, below the required 135 degrees Fahrenheit, indicating improper hot holding of food.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide timely feeding assistance to two residents, resulting in their meals not being consumed promptly and potentially being served at inappropriate temperatures. Resident R23 was observed asleep in bed with an undisturbed food tray on the bedside table. Despite multiple staff members assisting with tray pass, R23's tray remained untouched until a CNA was interviewed and confirmed that R23 required assistance to wake up and set up the food tray. R23's medical history includes Alzheimer's disease, anxiety disorder, dementia, dysphagia, and protein-calorie malnutrition, with a care plan indicating the need for assistance with activities of daily living due to generalized weakness. Similarly, Resident R69 was found alert in bed with a covered food tray on the bedside table. When interviewed, R69 indicated readiness to eat and required assistance with tray setup. An LPN later assisted R69 with the food tray setup and eating. R69's medical history includes diabetes mellitus type two, major depressive disorder, cerebral infarction, and vascular dementia, with a care plan noting the need for assistance with activities of daily living due to these conditions. The Director of Nursing acknowledged that staff should assist residents with their meals when trays are brought into the room, as per the facility's Food and Nutrition Services policy.
Failure to Follow Up on Dental Care for Resident with Medicaid
Penalty
Summary
The facility failed to follow up on a dental recommendation for a resident with Medicaid benefits, resulting in the resident not having several broken and decayed teeth extracted. The resident, who was observed with visible broken and decayed teeth, complained of tooth pain, tooth abscess, and difficulty eating. The resident had been admitted with diagnoses of convulsions, seizures, and altered mental status, and had moderately impaired cognition. The resident's Medicaid insurance was accepted on 7/10/24, but no dental appointment was made despite a previous dental summary report indicating the need for tooth extractions. The facility's policy requires the Social Service Staff to assist residents in securing dental appointments when needed. However, the Nursing Home Administrator acknowledged that an appointment was not made for the resident after Medicaid acceptance, likely due to the recent departure of the social worker responsible for setting up dental appointments. The lack of follow-up documentation and the absence of a scheduled dental visit or tooth extractions contributed to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Southgate
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rivergate Health Care Center | 0.9 mi | ★★★★★ | 4 | 0 |
| Rivergate Terrace | 0.9 mi | ★★★★★ | 13 | 0 |
| Belle Fountain Nursing & Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Aerius Health Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Optalis Health And Rehabilitation Of Allen Park | 3.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.