Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southwood Nursing And Retirement during CMS and state inspections, most recent first.
A resident with type 2 diabetes did not receive insulin as ordered due to a missed dosage when taken out for an appointment and a documentation error leading to inaccurate BS records. The DON and nurse acknowledged the errors, and the resident reported no adverse effects.
A resident with chronic respiratory failure and hypoxia was not receiving oxygen at the physician-prescribed rate of 2 liters per minute. Observations revealed the oxygen concentrator was set at 1.5 liters per minute, which was confirmed by the resident and Nurse #1. The resident's oxygen saturation improved after the setting was corrected. The facility's staff were expected to adhere to physician orders for oxygen therapy.
A facility failed to maintain accurate EMR for a resident with type 2 diabetes. The DON did not document a missed insulin dose when the resident left for an appointment, and a nurse recorded the same blood sugar level and insulin dose twice on another occasion. The administrator expected accurate documentation.
A resident with multiple health conditions, including osteoporosis, was injured during a transfer when a new agency nurse aide failed to use the required mechanical lift. Despite the resident's care plan specifying the need for a lift and two staff members, the aide attempted a manual transfer, resulting in a fall and a fractured femur. The incident highlighted a lack of proper orientation and training for new staff.
A facility failed to properly orient an agency NA on her first day, resulting in the unsafe transfer of a resident who was subsequently hospitalized with a fractured femur. The NA was not provided with an orientation packet or trained on the facility's systems and transfer methods, leading to the incident. Interviews with staff confirmed the lack of orientation and training for the NA.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer insulin medication as ordered by the physician for a resident with type 2 diabetes mellitus, leading to a deficiency in medication administration. On one occasion, the resident's blood sugar (BS) was checked, but the insulin was not administered because the resident was taken out of the facility for an appointment. The Director of Nursing (DON) acknowledged the failure to document the missed dosage of insulin. On another occasion, there was a discrepancy in the documentation of the resident's BS levels and insulin administration, with the same BS value recorded at two different times, which the nurse attributed to a documentation error. Interviews with the DON, the nurse involved, and the medical director confirmed the inaccuracies in documentation and the failure to follow physician orders. The resident reported missing BS checks and insulin doses but did not experience any adverse effects. The medical director emphasized the importance of following physician orders, and the administrator expected the nursing staff to administer medications as prescribed.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to administer oxygen at the physician-prescribed rate for a resident with chronic respiratory failure and hypoxia, who was dependent on supplemental oxygen. The resident was admitted with a physician's order for oxygen at 2 liters per minute via nasal cannula. However, during observations, the oxygen concentrator was set to deliver oxygen at 1.5 liters per minute instead of the prescribed 2 liters. The resident, who was cognitively intact, confirmed that the setting was incorrect and denied changing it. Nurse #1, who was responsible for the resident's care, was unaware of the incorrect setting and had not changed it. She confirmed that the resident's oxygen saturation was 97% when checked earlier in the day, but it dropped to 94% when the incorrect setting was observed. After adjusting the concentrator to the correct setting of 2 liters per minute, the resident's oxygen saturation improved to 97%. Interviews with the Nurse Practitioner and the Director of Nursing revealed that it was expected for nursing staff to adhere to physician orders for oxygen therapy, ensuring the correct settings on oxygen concentrators.
Inaccurate EMR Documentation for Diabetic Resident
Penalty
Summary
The facility failed to maintain a complete and accurate electronic medical record (EMR) for a resident with type 2 diabetes mellitus. The resident was admitted with a diagnosis that required careful monitoring and administration of insulin according to a sliding scale. On one occasion, the Director of Nursing (DON) did not document the resident's blood sugar (BS) level or the missed insulin dosage in the Medication Administration Record (MAR) after the resident left for an appointment before the scheduled administration. This lack of documentation was acknowledged by the DON during an interview. Additionally, there was an error in the documentation of the resident's blood sugar levels and insulin administration on another day. The MAR showed the same blood sugar level and insulin dosage recorded twice, which was later confirmed by Nurse #1 as inaccurate. The DON confirmed that the nurse would not have administered the insulin twice, indicating a documentation error. The facility's administrator expressed an expectation for accurate documentation by the nursing staff.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to provide a safe transfer for a resident, resulting in a serious injury. The resident, who was admitted with conditions including coronary artery disease, heart failure, end-stage renal disease, and osteoporosis, required a full mechanical lift with two staff members for all transfers. However, Nurse Aide #7, who was new to the facility, did not use the mechanical lift or seek assistance when transferring the resident from the bed to a recliner. This led to the resident experiencing severe knee pain and being lowered to the floor, eventually resulting in a fracture of the distal lateral left femoral metaphysis. The incident occurred when Nurse Aide #7, feeling pressured and unable to find help, attempted to transfer the resident manually. Despite the resident's request for assistance and the aide's acknowledgment of the need for help, the transfer was conducted without the required equipment or additional staff. The resident's knee pain was initially addressed with medication, but further medical evaluation revealed a fracture, confirming the injury was a result of the improper transfer. Interviews with the involved staff and the resident highlighted the lack of proper orientation and training for the new agency staff, which contributed to the incident. The resident's care plan clearly indicated the need for a mechanical lift, yet this was not followed, leading to the resident's fall and subsequent injury. The facility's failure to ensure that all staff were adequately trained and aware of the resident's transfer needs directly resulted in the deficiency.
Failure to Orient Agency Nurse Aide Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that an agency Nurse Aide (NA) was properly oriented and trained on her first day of assignment, which led to a deficiency in resident care. NA #7, who was working at the facility for the first time, was not provided with an orientation competency packet, nor was she trained on the facility's kiosk system, Kardex, or the specific transfer methods required for residents. As a result, NA #7 did not use a mechanical lift with assistance to transfer Resident #2, leading to the resident being transferred to the hospital with a fractured femur. This incident was identified during interviews with the NA, the Scheduler, the charge nurse, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, all of whom confirmed the lack of orientation and training for NA #7. The deficiency was further highlighted by the fact that the facility's procedure for orienting agency staff was not followed. The Scheduler and the charge nurse were responsible for ensuring that new agency staff received and completed orientation packets, but this did not occur for NA #7. The Administrator acknowledged that the orientation packet was not available for NA #7 on the day of the incident, which was a weekend, and that the procedure for training agency staff was not implemented in this case. This oversight resulted in NA #7 being unaware of the necessary procedures for safely transferring Resident #2, ultimately leading to the resident's injury.
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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 Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary Gran Nursing Center | 0 mi | ★★★★★ | 2 | 0 |
| Warsaw Rehabilitation And Healthcare Center | 13.2 mi | ★★★★★ | 5 | 0 |
| Kenansville Rehabilitation And Healthcare Center | 19.9 mi | ★★★★★ | 0 | 0 |
| Mount Olive Center | 19.9 mi | ★★★★★ | 14 | 1 |
| Liberty Healthcare Services Of Golden Years Nursin | 24.2 mi | ★★★★★ | 7 | 0 |
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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 August 2026) and official state health department websites.