Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southwell Health And Rehabilitation during CMS and state inspections, most recent first.
A WCC failed to follow infection control processes during wound care and suprapubic catheter care for a resident with quadriplegia, a stage 4 sacral pressure ulcer, an open lower back and pelvis wound, and an indwelling catheter. During observed care, the WCC cleaned the wound and catheter site but did not change gloves or perform hand hygiene before packing the wound and applying dressings; the WCC and DON both confirmed the missed infection control steps.
The facility failed to provide a 30-day revocation period for arbitration agreements, offering only 10 days instead. Additionally, two residents were not informed about agreements signed by family members. The Admissions Director and Administrator were unaware of the requirement for a 30-day period, using a hospital-based policy instead.
The facility's arbitration agreements for three residents failed to allow for a mutually agreed upon arbitrator and venue, specifying a particular arbitrator and location in Tifton, Georgia. This non-compliance was due to the use of a hospital-based arbitration agreement, as confirmed by the Admissions Director and Administrator, who were unaware of the requirement for mutual agreement.
A facility failed to obtain or follow up on a resident's advanced directive. The resident's family member indicated they had the document but did not provide it at admission. Facility policy requires staff to encourage submission and document reminders, but no follow-up was conducted. Interviews revealed that the Social Service Coordinator and Admission Director did not pursue obtaining the directive, leaving the resident's resuscitation status unclear.
A resident with a history of stroke and severe cognitive impairment reported being physically abused by a CNA, who allegedly slapped her hand and was rough during care. The facility's investigation confirmed the abuse, resulting in the CNA's termination. The facility's abuse prevention policies were found inadequate as they did not address expectations for preventing abuse in the LTC setting.
The facility lacked comprehensive policies for preventing and investigating abuse in the LTC setting. The existing system-wide policy focused on reporting compliance concerns and did not address specific long-term care requirements, such as staff vetting or abuse recognition. Interviews with the Compliance Manager and DON confirmed the reliance on inadequate policies, highlighting a gap in addressing abuse prevention and investigation in the facility.
A resident reported being slapped by a CNA, but the facility's investigation was incomplete, lacking interviews with other residents or staff. The resident, with a history of stroke and cognitive impairment, expressed fear of further harm. The Risk Manager's investigation did not extend beyond the resident and the accused CNA, leaving potential additional abuse unexamined.
A resident diagnosed with schizoaffective disorder was not referred for a Level II PASARR as required by the facility's policy. Despite the diagnosis by a psychiatrist, the necessary referral was not made due to communication and access issues among staff. The Social Services Coordinator was unaware of the diagnosis and lacked access to request PASARR Level II, while the Compliance and Accreditation Manager confirmed the oversight.
The facility failed to implement care plans for three residents, leading to potential inadequate care. A resident with heart failure was observed without prescribed compression stockings due to laundry issues. Another resident with heart failure also lacked compression stockings despite available extras. A third resident with a urinary catheter had the catheter bag improperly placed on the floor, risking infection. Staff acknowledged these deficiencies.
A resident with an indwelling urinary catheter did not receive appropriate care to prevent UTIs. The facility lacked physician orders for catheter size and change frequency, and the catheter was observed on the floor multiple times. Staff were unsure of the catheter's rationale, and the facility had no catheter care policy. The care plan's interventions were not effectively implemented, leading to potential infection risks.
A resident with quadriplegia was found with bed rails in use without proper assessment, physician orders, or informed consent. The facility's policy requires these steps, but they were not followed, creating a potential safety risk. The resident was unable to use the bed rails due to his condition, and the Compliance Manager confirmed the oversight.
Infection Control Lapse During Wound and Catheter Care
Penalty
Summary
The facility failed to ensure the Wound Care Coordinator followed infection control processes during wound care and suprapubic catheter care for a resident with quadriplegia, an open wound of the lower back and pelvis, a stage 4 sacral pressure ulcer, and bed confinement status. The resident’s MDS documented dependence for care, an indwelling catheter, one unhealed stage 4 pressure ulcer, use of a pressure-reducing device, a turning/repositioning program, nutrition or hydration interventions, pressure ulcer care, and nonsurgical dressings. The care plan included skin integrity risk related to impaired mobility and sensation, a stage IV pressure ulcer to the coccyx, and a suprapubic urinary catheter. During observation of wound care, the WCC removed the outer dressing and packing, sanitized her hands, changed gloves, cleaned the sacral wound with Anasept spray, and then packed the wound with Anasept gel-moistened gauze using a cotton-tip applicator. She applied skin prep and covered the wound with a dressing without changing gloves or performing hand hygiene after cleaning the wound and before applying the new dressing. During suprapubic catheter care, the WCC sanitized her hands, put on gloves, cleaned the catheter insertion site with Anasept wound cleanser, and applied a split drain sponge/dressing without changing gloves or performing hand hygiene after cleaning the site and before placing the dressing. The WCC confirmed she missed the step of sanitizing her hands and changing gloves, and the DON stated the nurse should always sanitize hands and change gloves after cleaning a wound and before applying a new dressing.
Arbitration Agreement Revocation Period Deficiency
Penalty
Summary
The facility failed to ensure that the arbitration agreements for three residents provided a 30-day period to rescind the agreement, as required. Instead, the agreements only allowed for a 10-day revocation period. This discrepancy was identified during staff and resident interviews, as well as through record reviews. The arbitration agreements were part of the facility's Conditions of Service and Consent for Treatment, which were included in the Admission Agreement. The agreements stated that any disputes related to healthcare services would be resolved through binding arbitration, and residents were waiving their right to a jury trial. However, the agreements incorrectly stated that residents had only 10 days to revoke their consent. Additionally, two residents were not informed about the arbitration agreements signed by their family members. One resident, who was cognitively intact, was unaware of the agreement but trusted their family member to sign documents on their behalf. Another resident, also cognitively intact, was not informed about the agreement, which was signed by a family member who was not the primary decision-maker according to the resident's advance directives. The Admissions Director confirmed the use of a hospital-based arbitration agreement with a 10-day revocation period, unaware of the requirement for a 30-day period. The Administrator also acknowledged the discrepancy, attributing it to the use of a hospital-based policy.
Arbitration Agreement Lacks Mutual Agreement on Arbitrator and Venue
Penalty
Summary
The facility failed to ensure that arbitration agreements for three residents allowed for a mutually agreed upon arbitrator and venue. The arbitration agreements specified a particular arbitrator and location in Tifton, Georgia, which did not comply with the requirement for both parties to agree on the arbitrator and venue. This issue was identified during a review of the facility's Conditions of Service and Consent for Treatment, which included the arbitration agreement as part of the Admission Agreement. Interviews with the Admissions Director and the Administrator revealed a lack of awareness regarding the requirement for mutual agreement on the arbitrator and venue. The Admissions Director admitted to implementing the hospital's arbitration agreement, which is part of the same organization, without knowledge of the specific requirements. The Administrator also acknowledged the discrepancy, stating that the arbitration agreement was hospital-based, which led to the specification of the arbitrator and venue in the agreement.
Failure to Obtain and Follow Up on Resident's Advanced Directive
Penalty
Summary
The facility failed to ensure they had a copy or had followed up to obtain the Advanced Directive for one resident, identified as R80. At the time of admission, R80's family member, F80, indicated that they had the advanced directive documentation but did not bring it to the facility. The facility's policy requires personnel to encourage the patient or representative to provide a copy as soon as possible and to include a reminder in the patient's medical record. However, there was no documentation in R80's electronic medical record indicating that the advanced directive was provided or that follow-up was conducted to obtain it. Interviews with facility staff revealed a lack of follow-up regarding the advanced directive. The Social Service Coordinator (SSC) stated that she typically followed up if advanced directives were not provided, but in this case, she did not follow up with F80. The Admission Director confirmed that while she asked for the advanced directive at admission, she did not follow up afterward, leaving the responsibility to the SSC. R80, who was cognitively intact, deferred decisions regarding resuscitation to F80, indicating uncertainty about the advanced directive in place. The facility's administrator verified that staff should have followed up to obtain the advanced directive copies.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically a Certified Nurse Assistant (CNA). The incident involved a resident who alleged that she was slapped hard on the hand by CNA 1. The resident, who had a history of stroke and was severely cognitively impaired at the time of the incident, reported that the CNA was rough during care, loud, and did not stop when the resident yelled for help. The resident expressed fear of the CNA, stating she was afraid the CNA might smother her with a pillow. The facility's investigation confirmed the resident's allegations, leading to the suspension and subsequent termination of CNA 1. The facility's policies on abuse prevention were found lacking, as the provided policy did not address expectations related to the prevention of abuse in the long-term care setting. Interviews with the resident, the Director of Nursing, and the health care system's Risk Manager corroborated the incident and the actions taken against CNA 1.
Inadequate Abuse Prevention Policies in LTC Facility
Penalty
Summary
The facility failed to ensure that comprehensive policies and procedures were in place to prevent and investigate abuse in the long-term care setting. The existing policy, titled Compliance Investigations, dated 1/1/2020, was system-wide and primarily focused on reporting potential compliance concerns. It did not address specific expectations related to the prevention of abuse and neglect, such as mandatory staff vetting prior to hire or staff recognition of abuse. Additionally, it lacked the necessary elements for investigating allegations of potential abuse in the long-term care environment. Interviews with the Health System's Compliance and Accreditation Manager and the Director of Nursing (DON) revealed that the facility relied solely on the healthcare system's Compliance Investigations Policy, which did not meet the specific requirements for long-term care. The Compliance and Accreditation Manager confirmed that the policy only covered reporting timeframes and did not include procedures for abuse prevention or investigation. The DON acknowledged the absence of specific long-term care policies and indicated that there had been an attempt to merge the facility's policies with the healthcare system's hospital policies, which were more focused on risk management rather than the specific needs of long-term care.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported being slapped on the hand by a CNA. The investigation was limited to interviews with the resident and the accused CNA, without extending to other residents or staff who might have witnessed or experienced similar incidents. The facility's abuse prevention policies did not specifically address the expectations for investigating potential abuse allegations, which contributed to the incomplete investigation. The resident involved had a history of stroke and was initially cognitively intact, but later assessments indicated severe cognitive impairment. Despite the resident's report of rough treatment and fear of further harm, the investigation did not include interviews with other residents or staff to determine if there were additional instances of abuse by the CNA. The facility's Risk Manager conducted the investigation but did not gather statements from other potential witnesses or victims, leaving the investigation incomplete.
Failure to Refer Resident for PASARR Level II After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident diagnosed with schizoaffective disorder was referred for a Level II Pre-Admission Screening and Resident Review (PASARR) as required. The facility's policy mandates that when a mental disorder diagnosis is identified, appropriate services and treatment should be provided, including a PASARR Level II referral. However, despite the resident's new diagnosis of schizoaffective disorder by a psychiatrist, the facility did not initiate the necessary referral process. Interviews with facility staff revealed gaps in communication and access to PASARR processes. The Social Services Coordinator (SSC) indicated that she was unaware of the resident's new diagnosis and lacked electronic access to request PASARR Level II. The Compliance and Accreditation Manager confirmed that the resident had not been referred for the necessary PASARR Level II evaluation. The facility's Administrator acknowledged that the referral should have been made following the diagnosis, highlighting a breakdown in the facility's adherence to its own policies and procedures.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement the comprehensive care plan for three residents, leading to potential inadequate care. Resident 35, who was admitted with combined systolic and diastolic heart failure and vascular dementia, was observed multiple times without the prescribed compression stockings, which were intended to manage fluid volume excess and prevent edema. Interviews with nursing staff revealed that the stockings were not available due to laundry issues, and there was only one pair available for the resident. Similarly, Resident 71, with chronic systolic congestive heart failure, was also observed without the required compression stockings, despite physician orders and care plan interventions specifying their use during the daytime. The Director of Nursing confirmed that extra stockings were available, yet they were not utilized. Additionally, Resident 25, who had an indwelling urinary catheter, was found with the catheter bag lying directly on the floor, posing a risk of infection. The care plan required catheter care every 12 hours, but there were no specific physician orders for changing the catheter, and staff acknowledged the improper placement of the catheter bag.
Inadequate Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was moderately impaired in cognition, had a catheter without documented physician orders specifying the size or frequency of changes. The medical director and attending physician were unsure of the rationale for the catheter, and the resident herself was unaware of the reason for its use. The catheter was initially inserted in the hospital due to urinary retention and obstruction, but this information was not adequately documented or communicated within the facility. During the survey, the resident's catheter and tubing were observed resting on the floor on multiple occasions, which was confirmed by staff interviews. The catheter bag was not properly secured, and staff acknowledged that it should not be on the floor due to the risk of infection and potential for dislodgement. The facility lacked a policy and procedure for catheter care, and there were no physician's orders detailing when the catheter should be changed or the size of the catheter. The facility's care plan for the resident included goals for optimal bladder function and interventions to evaluate for symptoms of UTI, promote hydration, and ensure proper catheter care. However, these interventions were not effectively implemented, as evidenced by the catheter's improper placement and lack of specific physician orders. The Director of Nursing confirmed that the catheter bag should be hung and not placed on the floor, and there should be clear orders for catheter management.
Failure to Assess and Document Bed Rail Use for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R27, was properly assessed and documented for the use of bed/side rails. Despite the facility's policy requiring an evaluation for bed rail use, a physician's order, a care plan update, and informed consent, these steps were not followed for R27. The resident, who was admitted with a diagnosis of quadriplegia, was observed with bilateral 1/3 bed/side rails in the raised position on multiple occasions. However, the resident's records, including the Admission Record, Annual Minimum Data Set (MDS), and Physician's Orders, did not reflect the use of bed/side rails, nor was there any documentation of informed consent or a recent bed rail assessment. Interviews with the resident and the Compliance and Accreditation Manager confirmed the oversight. R27, who was cognitively intact but completely dependent on staff for mobility due to quadriplegia and contractures, stated he was unable to use the bed/side rails. The Compliance and Accreditation Manager acknowledged the absence of necessary documentation and confirmed that R27 should not have had bed/side rails, as he was unable to use them. This lack of compliance with the facility's policy created a potential risk for the resident's safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Adel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berrien Oaks Nursing And Rehab Center | 12.9 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Lakehaven, Llc | 18.4 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Valdosta, Llc | 18.8 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Crestwood, Llc | 18.9 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Holly Hill, Llc | 18.9 mi | ★★★★★ | 10 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.