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On the day he was found unresponsive and without a pulse, none of those measures were attempted.

The Director of Maintenance told the inspector that staff first flagged the damaged ceiling tile about three weeks before the inspection, on a Friday.

The inspection, completed September 4, 2025, was triggered by complaints and resulted in a citation for actual harm.

Inspectors visited Southwood Healthcare Center on September 4, 2025, responding to a complaint.

The inspection at The Villa at Green Lake Estates, triggered by a complaint, focused on the care of a single resident identified in records as R103.

The letter described a problem with how she interacted with residents.

She had been at the facility less than a week when inspectors arrived on September 2, 2025.

The problem was in how nurses transferred medication orders into the facility's electronic records system when patients were admitted or readmitted.

A licensed practical nurse had stepped away for a break at 8:55.

The resident, identified in inspection records only as R302, was a patient at Optalis Health and Rehabilitation of Troy, a rehabilitation facility at 925 W.

That was one of the findings federal inspectors documented during a September 4 complaint inspection at the Burke County facility.

The deficiency, cited under F0641, concerns how the facility documents wounds on residents who arrive already injured.