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Complaint Investigation

Southwood Healthcare Center

September 4, 2025 · Terre Haute, IN · 2222 Margaret Ave
Citations 2
CMS Rating 1/5
Beds 121
Provider ID 155484
Healthcare Facility
Southwood Healthcare Center
Terre Haute, IN  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

SOUTHWOOD HEALTHCARE CENTER in TERRE HAUTE, IN — inspection on September 4, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0610
Freedom from Abuse, Neglect, and Exploitation Deficiencies

During an interview, with the ED and the RDCO, on 9/4/25 at 9:49 a.m., the ED indicated she and the RDCO were in the building when the incident happened, and the staff immediately notified her.

She made the decision to suspend the CNA at that time.

She indicated a skin assessment should have been done after the resident received the skin tear.

She was unsure why there was not an assessment completed until 8/22/25. At the same time, the RDCO indicated they interviewed staff who had been working on the unit at the time of the incident.

The staff indicated they could not determine that any type of abuse had been committed. He thought they had obtained individual statements from the staff who were interviewed but were not able to locate them.

On 9/4/25 at 10:57 a.m., the ED provided a written statement from a housekeeper who indicated she was not on the unit during the time of the incident. No other statements were presented.

During an interview, on 9/4/25 at 11:38 a.m., the ED indicated they had not been able to find any further documentation for this investigation.

The nurse on the unit during the incident with the CNA had been interviewed and a statement was written.

However, they could not find a copy of this statement.

She had contacted the nurse, via telephone, and the nurse remembered writing a statement, but she did not have a copy of it.

On 9/3/25 at 11:14 a.m., the ED provided an undated document, titled, “Indiana Abuse & Neglect & Misappropriation of Property,” and indicated it was the policy currently being used by the facility.

The policy indicated, “…Investigation of Incidents…1…e.

Statements will be obtained from the resident or from the reporter of the incident…g.

Documentation of the facts and findings will be completed in each resident medical record…2.

Suspected Abuse…d.

Statements will be obtained from staff related to the incident, including victim, person reporting the incident, accused perpetrator and witnesses.

This statement should be in writing, signed, and dated at the time written….” This citation relates to Intake 2591628. 3.1-28(d)

155484 09/04/2025

Southwood Healthcare Center 2222 Margaret Ave Terre Haute, IN 47802

During an interview, on 9/4/25 at 10:00 a.m., Licensed Practical Nurse (LPN) 5 indicated that the nurses would have to administer insulins to the residents on the halls that had a Qualified Medication Aide (QMA) working because QMAs were not allowed to give insulin injections. LPN 5 indicated it could be hard to administer the insulin medication on time if the nurse didn't prioritize her time management properly.

During an interview, on 9/4/25 at 10:10 a.m., Registered Nurse (RN) 6 indicated that she would often get the insulin medications administered on time, but she would not always get the insulin documented at the time of administration; therefore, on the medication administration record it would appear as if the medication was administered late.

During an interview, on 9/4/25 at 10:31 a.m., the Director of Nursing (DON) indicated staff should document the administration of medications when they were administered to the residents to ensure adequate documentation.

On 9/4/25 at 10:48 a.m., the DON provided a document, dated 12/2/24, titled, Medication Administration, and indicated it was the currently policy being used by the facility.

The policy indicated, .MAR: Medication Administration Record - the legal documentation for medication administration .f.

Observe the five rights in giving each medication: .ii. the right time .dd.

Medications will be charted when given .a.

Documentation of medication will be current for medication administration b.

Documentation of medications will follow accepted standards of nursing practice This citation relates to Intake 2602845. 3.1-50(a)(2) 3.1-50(f)

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TERRE HAUTE, IN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SOUTHWOOD HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.