Southwood Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 9, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect, when the facility failed to ensure a resident was provided adequate monitoring and care during the night shift for 1 of 4 residents reviewed for neglect (Resident B). The immediate jeopardy began on [DATE] when staff failed to visualize a resident during the 8-hour night shift and the resident was found deceased on the floor between the bed and wheelchair the next morning at 7:15 a.m. The Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and a RDCO in training were notified of the immediate jeopardy on [DATE] at 4:52 p.m. […]

• Immediate jeopardy, isolatedF725Oct 9, 2025

  Based on interview and record review, the facility failed to ensure sufficient staffing was provided to care for and supervise the residents that resided at the facility for 1 of 7 residents reviewed for sufficient staffing (Resident B). The immediate jeopardy began on [DATE] when the facility staff failed to provide care and supervision of residents residing at the facility during the eight hour night shift resulting in a resident not being checked on all night and was found deceased on [DATE] at 7:15 a.m. The Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO), and a RDCO in training were notified of the immediate jeopardy on [DATE] at 4:52 p.m. […]

• Immediate jeopardy, isolatedF689May 1, 2023

  Based on interview and record review, the facility failed to ensure supervision of a moderately cognitively impaired resident with a history of diabetes, mental illness, illicit drug use, and new onset aphasia; and failed to follow the facility elopement policy resulting in a delay in contacting the police for approximately 20 hours after the resident had gone missing for 1 of 4 residents reviewed for quality of care (Resident B). The immediate jeopardy begun on [DATE] at 8:30 p.m., after Resident B was witnessed by her peers to be upset and tearful and left the facility without signing out as she usually did. Staff became aware Resident B was missing at approximately 8:30 p.m. when she was unable to be located for her evening medication administration. […]

• Actual harm, isolatedF760Sep 10, 2021

  Based on interview and record review, the facility failed to protect a resident (Resident G) from receiving another resident's medication (Resident F) occurred resulting in harm when the resident received an overdose of an opioid (narcotic pain medication) causing difficulty to arouse, shallow breathing pattern which resulted in [MEDICATION(S)] (used to treat narcotic overdose in emergency situation) being administered and the resident was admitted to the hospital for 1 of 3 residents reviewed for medication errors (Resident G). Findings include: Resident G's record was reviewed on 9/9/21 at 2:30 p.m. A facility census indicated the resident admitted to the facility on [DATE]. A nurse's progress note, dated 8/12/21 at 11:47 p.m., indicated the writer was notified of a medication error. […]

• Actual harm, isolatedF686May 5, 2021

  Based on observation, record review, and interview, the facility failed to ensure interventions and treatments for pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) were implemented for 1 of 9 residents reviewed for pressure ulcers resulting in harm when a resident developed an avoidable unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) pressure ulcer on the left heel that worsened to a stage four (a sore that extends below the subcutaneous fat into deep tissues like muscle, tendons, and ligaments; in more severe cases, they can extend as far down as the cartilage or bone), and developed an avoidable unstageable pressure ulcer to the right heel (Resident J). […]