Southwood Healthcare Center
SOUTHWOOD HEALTHCARE CENTER in TERRE HAUTE, IN — inspection on October 9, 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
During an interview, on [DATE] at 1:30 p.m., QMA 6 indicated she worked night shift on [DATE] into
jeopardy to resident health or room because she did not require medications. QMA 6 indicated she completed one round when her safety shift started and opened Resident B's door, sometime between 10:30 p.m. and midnight.
She thought Resident B was in bed, but she did not actually see Resident B. QMA 6 indicated she observed
QMA 6 did not fully enter the room to visualize Resident B.
There was one nurse in the facility and one CNA assigned to Resident B's unit, one other unit, and part of a third unit. CNAs should have done bed checks every two hours.
Resident B was independent, but she thought staff should have checked on the resident at least a couple of times a night. QMA 6 indicated she did not think there was enough staff on night shift to take care of the residents and check on them the way they need to.
The staff was very spread out, and it was hard during emergencies.
She would have to look for other staff for help. It was hard for the staff to take breaks, and the night shift nurse never took a break.
Staffing was the worst on nights. CNA 5 assigned to Resident B had left the written report because the CNA had worked a double shift, evening shift on [DATE] and night shift from [DATE] into the morning of [DATE], and was assigned to work eight hours later, evening shift on [DATE]. CNA 5 had to leave the facility because she had to be back at work less than eight hours later.
During an interview, on [DATE] at 2:52 p.m., the RDCO indicated Resident B had not wanted staff in her room at night.
Resident B's preference should have been included on the care plan, but it was not. If a resident requested not to be checked on every two hours, resident education should have been provided, and the care plan should have been updated. On [DATE] at 1:39 p.m., the RDCO provided an undated document, titled, Nurse Aid Rounds, and indicated it was the policy currently being used by the facility.
The policy indicated, .Policy: .CNA's.provide patient centered care by monitoring patient care needs and safety on a routine basis throughout the day.Procedure: 1. CNA's will routinely monitor residents.for routine care needs and safety.referred to as rounding.2.
Rounding will be completed by CNA to safely transfer care between on-coming and off-going shifts.3.
Nurses will monitor that rounding schedule is adequate and complete for meeting resident needs. On [DATE] at 10:50 a.m., the RDCO provided an undated document titled, Abuse & Neglect & Misappropriation of Property, and indicated it was the policy currently being used by the facility.
The policy indicated, .Neglect: In Indiana, neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness (Deprivation of services).
Examples: An action or lack of action that actually harms a resident such as.7) An action or lack of action that places one or more residents in a life-threatening situation, such as.c) Staff failing to identify, assess, monitor, and respond to residents suffering an acute condition.II.
Training: 1.
Provide education and training upon hire, annually and as needed for re-training to include but not limited to.e.
Observations that may identify abuse or neglect.III.
Prevention.3.
Staffing is established based on census, acuity level, needs, and is posted daily in a conspicuous area for residents, family and visitors.
The immediate jeopardy that began on [DATE] was removed on [DATE], when the facility ensured a systemic plan to include education and monitoring of staff to ensure staff provided supervision and required care to all residents residing at the facility.
The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring.
This citation relates to Intakes 2635111 and
- 3.1-27(a)(3)
155484 10/09/2025
Southwood Healthcare Center 2222 Margaret Ave Terre Haute, IN 47802
During an interview, on [DATE] at 10:44 p.m., QMA 15 indicated there was only one nurse on night shift.
She worked 12 hour shifts from 6:00 p.m. to 6:00 a.m., routinely.
She was assigned to the closed unit with a CNA, and the nurse covered the rest of the building. It was very hard to oversee and meet all the residents' needs.
During an interview, on [DATE] at 10:54 p.m., CNA 12 indicated she had worked at the facility for about a month and there had only been one nurse on duty for the night shift for the entire month.
She indicated it was always the same nurse who worked the night shift, and it was LPN
During an interview, [DATE] at 8:48 a.m., the RDCO indicated Quality Assurance Performance Improvement (QAPI) staffing audits were completed through [DATE], per the plan of correction (POC) for the staffing deficiency cited during the annual survey in [DATE]. In July they had an interim Administrator who felt that staffing was better and stopped all staffing audits except daily staffing calls.
Then when the current Administrator started, they began to do staffing audits again.
During an interview, on [DATE] at 8:55 a.m., the Administrator indicated the daily staffing calls were with their corporate office.
They discuss the census and the staffing numbers.
Corporate would suggest that they may require more staff, so they would advertise and offer different incentives.
The QAPI had begun performing staffing audits after she started her position as the Administrator.
During an interview, on [DATE] at 10:40 a.m., Resident N indicated the same nurse aide usually worked the unit on night shift.
When Resident N requested Tylenol, the nurse aide had to let the nurse know so it could be administered.
Resident N had to wait a long time sometimes to get the Tylenol after she requested it.
She heard the staff say there was only one nurse covering three units, but she was not sure.
She knew they did not have very many staff who worked the night shift, and it was not enough.
Resident N indicated she turned her call light on this morning before 6:00 a.m. to request Tylenol, and it took the nurse aide approximately half an hour to answer the call light.
The nurse aide told the resident she would let the nurse know she wanted Tylenol.
The nurse gave her the Tylenol at 7:00 a.m. with her other morning medications.
She thought this type of thing happened because they did not have enough staff and could not get to the residents more quickly.
During an interview, on [DATE] at 10:55 a.m., Resident P indicated it took a long time for him to get his pain medication. He had to request medication and waited as long as nine hours after his request until he received it.
There was no nurse specifically assigned to his unit, so he had to wait for one to come to the unit and give him the pain medication after he asked for it.
During an interview, on 10/9/
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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.