Southwood Healthcare Center: Abuse Probe Failures - IN

Inspectors visited Southwood Healthcare Center on September 4, 2025, responding to a complaint. What they found was not a covered-up investigation. It was something in some ways more troubling: an investigation that facility leadership believed they had conducted, but could not show anyone.

The resident at the center of the case, identified in inspection records as Resident C, received a skin tear at some point before August 17, 2025. The facility's own executive director, referred to in the report as the ED, said she was in the building when the incident happened and that staff notified her immediately. She made the decision to suspend the CNA on the spot.

That part moved quickly. What followed did not.

A skin assessment, the kind of basic clinical documentation that establishes the nature and severity of a wound, was not completed until August 22, five days after the facility interviewed the resident. The ED told inspectors she was unsure why it had taken that long.

Resident C, when interviewed by the ED and the Regional Director of Clinical Operations on August 17, said he was not sure how he received the skin tear. He said he did not feel afraid of any staff on the unit and that he felt safe there. That interview was documented. Most of what came after was not.

The interview record noted that the ED and the Regional Director of Clinical Operations had spoken with staff who were working on the unit at the time of the incident. But the document listed no names. No job titles. No individual statements. Just a summary conclusion: staff could not determine that any type of abuse had been committed.

During their interview with inspectors on the morning of September 4, the Regional Director of Clinical Operations said he believed individual written statements had been obtained from those staff members. He could not find them.

The nurse who had been on the unit during the incident with the CNA was one of the people who should have provided a statement. According to the ED, that nurse had been interviewed and had written something down. But the facility did not have a copy. When the ED reached the nurse by phone, the nurse remembered writing a statement. She did not have a copy either.

By 10:57 that morning, the only written staff statement the ED was able to produce for inspectors was from a housekeeper. The housekeeper's statement said she was not on the unit during the incident.

That was it. One statement, from someone who was not there.

At 11:38 a.m., the ED told inspectors they had not been able to find any further documentation for the investigation.

The CNA at the center of the suspension had submitted a written statement. It was undated. It contained no description of any contact with the resident, no account of a fall, and no explanation of how the resident might have received the skin tear. The statement did not address the incident in any meaningful way.

The facility's own written policy, a document the ED provided to inspectors and identified as the one currently in use, was explicit about what an investigation into suspected abuse was supposed to look like. Statements were to be obtained from the resident, the person who reported the incident, the accused, and any witnesses. Those statements were to be written, signed, and dated at the time they were written. Documentation of facts and findings was to be completed in the resident's medical record.

None of that had been done in any verifiable way.

What makes the failure harder to explain is that the executive director was present when the incident occurred. This was not a situation where management learned about an alleged incident days later through a written report and had to reconstruct events from memory. The ED was there. She made an immediate personnel decision. And still, the documentation that her own facility's policy required does not exist, or cannot be located, which for practical purposes amounts to the same thing.

The Regional Director of Clinical Operations, who participated in the August 17 interview with Resident C and who told inspectors he believed written statements had been collected from staff, could not produce them. He thought they existed. They were not there.

Inspectors cited the facility under F0610, which covers the obligation to investigate allegations of abuse and to do so thoroughly, with proper documentation. The level of harm was assessed as minimal harm or potential for actual harm, and the deficiency was noted as affecting few residents.

That classification reflects the scope of the documented incident. It does not resolve the central question the investigation was supposed to answer: how did Resident C receive a skin tear, and did someone on staff cause it.

The CNA was suspended. Whether that suspension led to termination, reinstatement, or any other outcome is not addressed in the inspection report. The nurse whose statement cannot be found remembered writing it. The staff members whose names were never recorded in the investigation summary apparently told the Regional Director of Clinical Operations that they could not confirm abuse had occurred. Whether any of them were ever asked to put that in writing, sign it, and date it, as the facility's own policy required, is unknown.

Resident C said he felt safe. He said he did not know how he got the skin tear.

Five days passed before anyone formally assessed the wound.

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.

Additional Resources

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