Southwestern Veterans Center

In the surveyor’s words

From the most serious findings on record at Southwestern Veterans Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 5, 2021

  Based on a review of clinical records, facility staff education documents, facility specific documents, and staff interviews, it was determined that the facility failed to make certain that residents were protected from an unsafe chemical that resulted in actual harm for a resident (Resident R1) when the resident ingested drain cleaner resulting in [CONDITION(S)] injury, hospitalization and intubation. This failure created a past non-compliance Immediate Jeopardy situation for 25 of 36 residents who were able to reach the top of the maintenance cart and resided on the dementia unit. […]

• Immediate jeopardy, isolatedF689Jan 6, 2024

  Based on review of facility policy, clinical records, facility documentation, facility investigation and staff interviews, it was determined that the facility failed to provide adequate supervision for one of three residents (Resident R1), which resulted in actual harm when an unsupervised fall occurred, and Resident R1 sustained multiple rib fractures, punctured lung and hospitalization which resulted in death. This failure created an Immediate Jeopardy situation for one of three residents (Resident R1). […]

• Actual harm, isolatedF600Aug 19, 2026

  Based on review of facility policy, facility and clinical record documentation, and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R2) was free of neglect during care which resulted in actual harm of a laceration (tear in the skin and underlying tissue) to the left forehead requiring five sutures (specialized threads or strands used to stitch together tissues following an injury or surgical procedure). This deficiency is cited as past non-compliance. […]

• Actual harm, isolatedF689Aug 19, 2026

  Based on review of facility policy, facility and clinical record documentation, and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety, resulting in a preventable accident and actual harm when the resident received a laceration (tear in the skin and underlying tissue) to the left forehead requiring five sutures (specialized threads or strands used to stitch together tissues following an injury or surgical procedure), for one of two residents reviewed (Resident R2). This deficiency is cited as past non-compliance. […]

• Actual harm, isolatedF600Sep 26, 2025

  Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of left femur (thigh bone). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 1/16/25, indicated the purpose of protocol is to give guidance to provide protections for the health, safety, welfare, and rights of each resident residing in the facility by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property, corporal punishment,… […]