Southwood Healthcare Center

F 0610

Review of the facility's incident investigation documentation, on 9/4/25 at 9:05 a.m., indicated the following:

Level of Harm - Minimal harm or potential for actual harm

a. An undated statement from CNA 3. The statement lacked documentation of any situation where the resident was contacted by the CNA, any fall, or other reason where a skin tear would have been received by the resident.

Residents Affected - Few b. An interview of Resident C, dated 8/17/25, conducted by the ED and the Regional Director of Clinical Operations (RDCO). The interview document indicated the resident was not sure how he received the skin tear. He denied being afraid of any staff on the unit and that he felt safe on the unit. The document also included a statement which indicated that the ED and RDCO had interviewed the staff on the unit who had been working at the time of the incident. The statement lacked documentation of the names, titles, and individual statements by the staff who were interviewed.

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)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Southwood Healthcare Center

2222 Margaret Ave Terre Haute, IN 47802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842

Review of September 2025 MAR indicated the Lispro insulin medication was documented as administered at the following times:

Level of Harm - Minimal harm or potential for actual harm

a. On 9/1/25 the 7:30 a.m. dose was documented as administered at 9:02 a.m.

Residents Affected - Few

b. On 9/2/25 the 4:30 p.m. dose was documented as administered at 6:10 p.m.

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)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet