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Complaint Investigation

Southwood Healthcare Center

February 26, 2026 · Terre Haute, IN · 2222 Margaret Ave
Citations 1
CMS Rating 1/5
Beds 121
Provider ID 155484
Healthcare Facility
Southwood Healthcare Center
Terre Haute, IN  ·  View full profile →
Inspection Summary

SOUTHWOOD HEALTHCARE CENTER in TERRE HAUTE, IN — inspection on February 26, 2026.

Found 1 citation. 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.

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Inspection Findings

FF0805
Nutrition and Dietary Deficiencies

During an interview 2/25/26 at 1:36 p.m., CNA 1 indicated on 1/19/26 at approximately 12:00 p.m., the staff was passing the lunch trays.

She looked around the dining room and noticed Resident B was shoving food into her mouth and pocketing food in her cheeks.

She would normally feed herself and was a slow eater, so this was unusual.

She went over to Resident B and sat next to her to assist her to slow down her eating.

She was not chewing the food, just shoving into her mouth. CNA 1 moved her plate out of reach, in an attempt to get her to slow down and address the food in her mouth.

Her lips were turning bluish in color.

Resident B continued to reach for her plate to get more food. CNA 1 noted her bluish lip color and felt the resident was choking and performed the Heimlich Maneuver using two thrusts, positioning her clasped hands below her sternum with the resident seated. A whole Brussel sprout was expelled. LPN 2 arrived and took over care of Resident B. A lunch tray ticket, dated 2/19/26, Thursday lunch, for Resident B, indicated regular dysphagia advance diet.

Roasted Brussels Sprouts, Chop was listed on the resident's menu. A Preliminary Autopsy Report, provided by the coroner's office, completed 2/21/26, indicated the cause of death as acute pulmonary thromboembolism (blood clot in the lungs).

During an interview on 2/25/26 at 11:47 a.m., the Corporate Risk Management Nurse (CRMN) indicated the resident had been served whole Brussel sprouts, but according to her ordered diet, should have been served chopped Brussel sprouts. A current facility policy, undated, titled, Textures, provided by the Administrator on 2/26/26 at 10:24 a.m., included the following: .2.

Dysphagia advanced .Listed as dys adv on the meal ticket .Foods allowed: .Vegetables: soft, well-cooked.

This deficient practice was corrected by 2/20/26 prior to the start of the survey and was therefore Past Noncompliance.

The facility implemented a systemic plan that included monitoring meal tray/diet accuracy and staff education regarding accurate modified diet service, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI).

This citation relates to Intake 2748939.

These deficiencies reflect State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-20(a).

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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.


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