Southwood Healthcare Center: Abuse Probe Failures - IN
That is what inspectors found at Southwood Healthcare Center on September 4, 2025, when they reviewed the facility's response to an incident involving a resident identified in records as Resident C, a man who had turned up with a skin tear of unexplained origin sometime in mid-August.
Nobody could say exactly how he got it.
Resident C himself told the executive director and the Regional Director of Clinical Operations during an interview on August 17 that he was not sure how he received the skin tear. He said he did not feel afraid of any staff on the unit. He said he felt safe. That interview was documented. What was not documented, in any meaningful way, was what the staff said.
The interview summary noted that the executive director and the regional director had spoken with staff members who were working on the unit at the time of the incident. It did not include their names. It did not include their titles. It did not include what any of them actually said. The document recorded a conclusion, that staff could not determine that any type of abuse had been committed, without preserving the individual accounts that were supposed to support it.
When inspectors sat down with the executive director and the Regional Director of Clinical Operations on the morning of September 4, the regional director said he believed individual statements had been obtained from staff. He just could not locate them.
That answer, on its own, would have been damaging enough. But the investigation's failures ran deeper than missing paperwork.
The skin tear happened in mid-August. A skin assessment, the basic clinical step of documenting and evaluating the wound, was not completed until August 22. The executive director told inspectors she was unsure why. She had been in the building. She had suspended the CNA immediately. She acknowledged to inspectors that a skin assessment should have been done after the resident received the skin tear. She did not have an explanation for the five-day gap.
By late morning on September 4, the executive director had managed to produce one written statement related to the incident. It came from a housekeeper. The housekeeper stated she had not been on the unit during the time of the incident. No other statements were presented.
The nurse who had been working on the unit with the suspended CNA when the incident occurred had been interviewed at some point during the investigation. A statement had been written. The executive director told inspectors she had contacted the nurse by telephone, and the nurse remembered writing a statement. Neither the facility nor the nurse had a copy of it.
The facility's own written policy, an undated document titled "Indiana Abuse and Neglect and Misappropriation of Property" that the executive director provided to inspectors on September 3, described exactly what the investigation was supposed to look like. Statements were to be obtained from staff related to the incident, including the victim, the person reporting the incident, the accused perpetrator, and any witnesses. Each statement was supposed to be in writing, signed, and dated at the time it was written. Documentation of the facts and findings was to be completed in each resident's medical record.
None of that happened in any verifiable way.
What the facility had, weeks after suspending a CNA over an injury to a resident that no one could explain, was an interview summary with no names and no individual statements, a skin assessment that took five days to complete, a housekeeper's statement confirming she had not witnessed anything, and a nurse's statement that existed in the nurse's memory but nowhere else.
The regional director's position, when pressed, was that he thought the statements existed. The executive director's position was that she could not find them. By 11:38 in the morning, she told inspectors they had not been able to find any further documentation for the investigation.
It is worth being precise about what an abuse investigation is supposed to accomplish. When a resident is found with an unexplained injury and a staff member is suspended in connection with it, the investigation that follows is the mechanism by which the facility either substantiates or rules out abuse. Witness statements are not administrative formalities. They are the record of what people saw, what they heard, what they did or did not do. Without them, there is no investigation. There is only a suspension and a conclusion.
The conclusion here, that staff could not determine abuse had been committed, appeared in the interview summary without the underlying accounts that would allow anyone, including state inspectors, to evaluate whether that conclusion was reached responsibly or simply written down because it was the most convenient thing to write.
The inspectors cited the facility for failing to conduct a thorough investigation. The level of harm was recorded as minimal harm or potential for actual harm, affecting few residents. The citation connects to state intake number 2591628.
Resident C told investigators he felt safe on the unit. He was not sure how he got the skin tear. Those are the facts as he understood them, and they are the only individual account from that day that the facility managed to preserve in any complete form.
The nurse who was there wrote something down. It is gone. The other staff who were interviewed said things that the regional director believed were recorded. He could not find them. The CNA who was suspended was not mentioned in any surviving documentation by name or statement.
Resident C's wound went without a formal clinical assessment for five days after an incident serious enough to prompt an immediate suspension. By the time inspectors arrived, the facility could not reconstruct what its own employees had witnessed or said.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southwood Healthcare Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
SOUTHWOOD HEALTHCARE CENTER in TERRE HAUTE, IN was cited for abuse-related violations during a health inspection on September 4, 2025.
Nobody could say exactly how he got it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.