F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on staff interviews, record review, and policy review, the facility failed to immediately identify and
report allegations of abuse to the state survey agency for 1 of 1 sampled residents. (Resident #9)The
findings include:On 7/22/25, a review of the facility's federal report incident on 9/2/24 concerning the
allegation of assault made by Resident #9's representative on 9/2/24 was conducted. A summary of the
facility's interview with the participants states bruising was noted on the day shift (7:00 am-3:00 pm). The
bruising was noticed by the assigned Certified Nursing Assistant (CNA) K and documented by the day shift
assigned Nurse J on 8/31/24.On 7/22/25 a review of the nurse's notes was conducted. No nurses' notes
were documented on 8/31/24. However, a late entry note was entered on 9/2/24 at 11:01 am stating, Upon
entering on 8/31/24 at 8:15 am during medication administration, noticed black and blue bruise under the
right eye. Unknown cause, resident unable to verbally express the cause. Order to monitor area daily until
healed. Will continue to monitor.On 7/23/25 at approximately 5:00 PM, an interview was conducted with the
Risk Manager (RM). She confirmed the expectation is for all alleged violations of abuse, neglect,
exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property
are to be reported immediately but not later than two hours, and the results of all investigations of alleged
violations should be reported within five working days of the incident.On 7/24/25 at approximately 11:30
am, an interview was conducted with the Director of Nursing (DON). The DON stated the nurse did not
submit a federal report because she did not view it as abuse since she called the doctor and his order was
to monitor until healed. The DON confirmed an injury of an unknown source is required to be reported
within two hours. She further stated she was notified on 9/1/24. The Federal report was filed on 9/2/25
when Resident #9's representative observed bruise and contacted law enforcement.The facility's policy
titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property
(dated 12/02/2001, revised 11/15/2024) revealed, It is the policy of PruittHealth to actively preserve each
patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary
seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to
collectively in this policy as abuse, neglect, mistreatment, and exploitation). The Organization and its
partners should assure that best efforts are made to prevent any occurrences of any form of abuse,
neglect, and exploitation.The facility's policy titled Occurrences (dated 7/1/2012, revised 1/11/2024),
revealed Occurrence hazards are physical features in the healthcare center environment which may pose a
risk to a residentts safety, including but not limited to: Unexplained injury to a patient/resident where no
specific or actual incident was observed; yet the patient/resident exhibits evidence of an injury, such as a
bruise or skin tear. Reporting Occurrences: 1. Occurrences are to be reported to the Charge Nurse
immediately, no matter how minor they may appear. 2. Patient/resident care software incident entry must be
completed on the shift the occurrence took place. 3. If occurrence is noted without direct staff observation,
the incident
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
106140
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106140
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pruitthealth - Southwood
2301 Bluff Oak Way
Tallahassee, FL 32311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
entry must be completed in the software system on the shift the occurrence was reported. 4. Partners
witnessing an occurrence involving a patient/resident must report details of occurrence to his/her Charge
Nurse as soon as possible. Do not leave an occurrence victim unattended unless it is necessary to
summon assistance. Occurrence Documentation: I. The licensed nurse will be responsible for completing
the following occurrence documentation requirements prior to the end of the shift when the occurrence took
place. This documentation will be noted in the patient/resident's clinical record and in the occurrence
reporting software program. The Administrator or designee will complete the supervisor investigation on all
occurrences, and report to the appropriate state agency and/or other external agencies according to law.
This documentation is to be typed on the patient/resident care software occurrence report follow up section.
The Administrator's findings will include, but not limited to: Interview findings, Was abuse ruled out, if abuse
was noted list in detail type of abuse and who was involved, date of when report was completed, date
external agencies were notified, etc. Was abuse ruled out, if abuse was noted list in detail type of abuse
and who was involved, date of when report was completed, date external agencies were notified, etc. When
the physician and responsible party was notified. List any education and/or corrective action related to the
occurrence.
Event ID:
Facility ID:
106140
If continuation sheet
Page 2 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106140
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pruitthealth - Southwood
2301 Bluff Oak Way
Tallahassee, FL 32311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record reviews, the facility failed to implement the baseline care plan for 1 of 2
individuals reviewed for care plans. (Resident #35) The findings include:On 07/22/25 at approximately 9:50
AM during a visit with Resident #35, the resident was observed lying in bed wearing only a shirt and a brief.
The Director of Nursing (DON) and Staff B from Physical Therapy (PT) entered the room to respond to the
resident's complaint earlier that day. The resident was upset and tearful. She verbally expressed frustration
regarding her perceived lack of progress in therapy and a decline in her ability to perform functional tasks
independently. She specifically voiced a desire to regain the ability to use the bathroom independently and
shared concerns that she is not receiving sufficient therapy. She reported that she had been waiting in bed
for someone to assist her with getting up, using the bathroom, and performing hand hygiene. The resident
stated that she is at the facility to improve and return to her independent living situation and expressed
concerns over the current level of support. On 07/22/25 at approximately 9:55 AM, an interview was
conducted with Resident #35. She expressed feelings of frustration regarding a perceived delay in her
physical progress and continued dependence on staff for mobility and personal care. She reported that she
is still in bed at the time of the interview and has not yet had assistance to get up or attend therapy, which
she believes should have already begun. She feels strongly about going back to her independent living and
being able to walk to the bathroom independently. She further explained that she was continent but
currently wears a brief, explaining that this is due to her inability to independently access the bathroom.On
07/22/25 at approximately 3:25 PM, an interview was conducted with Staff C, Certified Nursing Assistant
(CNA). She is the sole caregiver assigned to the 100 and 200 halls, which currently house a total of 11
residents. When asked about bladder training, she stated that nursing restorative provides that service.
Regarding incontinence care, she acknowledges that the facility's expectation is to conduct rounds every
two hours, or more frequently if needed, to meet the residents' needs.On 07/23/25 at approximately 9:49
AM, an interview was conducted with the DON. She confirmed that the goal is to return Resident #35 to her
highest level of functioning and agreed that the resident, though not currently on a toileting program, would
benefit from one. The DON also acknowledged Resident #35's strong motivation to participate in therapy
and her goal of returning home to her prior level of functioning. She confirms that it is the facility's
expectation to provide the necessary services to support the residents in achieving these goals.On
07/23/25 at approximately 4:02 PM, an interview was conducted with the Physical Therapy Outcome
Coordinator. According to their documentation, Resident #35 ambulated distances of 80 feet, 90 feet and
150 feet with supervision or touching assistance. Transfers from sit to stand were performed with
partial/moderate assistance, requiring approximately 50% assistance. Resident #35 is a one person assist
for mobility and transfers.On 07/23/25 at approximately 5:00 PM, an interview was conducted with Staff E
(CNA). When asked about the level of assistance she provides Resident #35 for toileting needs, she
explained that she has not yet assisted with toileting since the resident's readmission on [DATE], despite
having worked five shifts with her, stating that the resident is incontinent. Additionally, she mentioned that
therapy staff take Resident #35 to the bathroom, but that she only provides incontinent care and does not
offer her toileting. She added that the resident is a limited transfer when she assists her to bed.On 07/23/25
at approximately 5:15 PM, an interview was conducted with the DON. She describes the facility's
expectations to check and assist residents with toileting and incontinence care every 2 hours. She reviewed
Resident #35's care plan dated 07/14/25, which stated: ADL needs will be met and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106140
If continuation sheet
Page 3 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106140
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pruitthealth - Southwood
2301 Bluff Oak Way
Tallahassee, FL 32311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
independence potential maximized and Improve ADL function to maintain independence through next
review. She recognized that since the documentation of the resident being continent on 06/27/25, toileting
the resident should be an intervention to meet the goal of the care plan and optimize the potential for the
resident to regain bladder control and her prior level of independence. A recent Physical Therapy (PT) note
dated 07/22/25 was reviewed that indicates Resident #35 was ambulating in therapy with touch assistance.
A review of progress notes from 06/25/2025, 06/27/2025, 06/28/2025 indicated the resident is alert and
oriented and able to communicate needs, continent of bowel and bladder and requires one person assist
with all transfers. A review of a progress note from 07/18/2025 indicated the resident requires one person
assist for Activities of Daily Living. A review of the discharge plan dated 07/23/2025 reveals resident plan to
return to Independent Living.On 07/23/25, the Minimum Data Set, dated [DATE] was reviewed. It stated that
the resident is using a wheelchair and walker for mobility device, accomplishes toileting with
partial/moderate assistance, and performs bed to chair transfer with Substantial assistance. It was also
revealed that a trial of a toileting program (schedules toileting, prompted voiding, bladder training) was not
attempted. A physical therapy note dated 07/22/25 states, Toilet transfer = Partial/moderate assistanceThe
Care Conference dated 06/23/25 noted that the Resident lives at an independent living. She has a rollator,
walker and bedside commode. The goal is to be able to walk again.On 07/24/25 at approximately 9:27 AM,
a policy titled: Care Plans effective 12/31/1996 and revised 07/23/23 was reviewed. Person Centered
Care-Focus is on the resident as the center of control. Supports each resident in making his or her own
choices. Includes making an effort to understand what each resident is communicating, verbally or
non-verbally, to identify what is important to each resident with regard to daily routines and preferred
activities and having and understanding of the resident's life before coming to reside in the health center.
Baseline Care-Plan must include the minimum healthcare information necessary to properly care for each
resident immediately after admission, which would address resident specific health and safety concerns to
prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance
with activities of daily living, as necessary. The comprehensive person-centered care plan is developed to
include measurable goals and timeframes to meet a resident's medical, nursing and psychosocial needs,
the services that are to be furnished to attain the resident's highest practicable physical, mental and
psychosocial needs that are identified in the comprehensive assessment. The type of goals may include
discharge goals, improvement goals, prevention goals and/or maintenance goals.On 07/24/25 at
approximately 9:47 AM, a policy titled Resident Rights effective 10/01/2029 and revised 12/01/2023 was
reviewed. It is the policy of this healthcare center to promote and protect the rights of the residents residing
in the center. The Center will make any effort to assist the resident in understanding and exercising her
rights to assure the resident is always treated with respect, kindness, and dignity. Each resident shall be
accorded privacy and freedom to use the bathrooms at all hours.
Event ID:
Facility ID:
106140
If continuation sheet
Page 4 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106140
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pruitthealth - Southwood
2301 Bluff Oak Way
Tallahassee, FL 32311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record review, interviews and facility policy review, the facility failed to develop a care plan for
2 of 2 residents sampled for Gerichair use (Residents #42 and #45) and 1 of 1 resident sampled for Hoyer
lift use (Resident #4).The findings include:Resident #4
On 07/21/2025 at 4:34 PM, Resident #4 was observed inside his room in a wheelchair waiting to be
assisted to bed. A few minutes later, Staff A, a Certified Nurse Assistant (CNA), was observed assisting the
resident from the wheelchair to the bed via Hoyer Lift. There was no other staff assisting during this
transfer.
On 07/21/2025 at 4:47 PM, an interview was conducted with Staff A, CNA. She stated she knew there were
supposed to be two staff members assisting with the Hoyer lift. She further stated the reason she was doing
it alone was because the resident had used the call light three times, and she could not find anyone to help
her.
A medical record review of Resident #4 was conducted. Resident #4 was admitted on [DATE] with
diagnoses including metabolic encephalopathy, sepsis, rhabdomyolysis, encounter for change or removal of
surgical wound dressing, local infection of the skin and subcutaneous tissue, open wound left hip, chronic
systolic heart failure, unsteadiness on feet, atrial fibrillation, cognitive communication deficit, hypertension,
type 2 diabetes mellitus, cerebral palsy, and adult failure to thrive. The plan of care included risk for falls and
impaired mobility with requiring assistance with transfers. The plan of care did not include use of Hoyer lift.
On 7/22/25 at 12:37 PM, an interview was conducted with Director of Nursing (DON). She was made aware
that the CNA was using the Hoyer lift alone. She stated it was facility policy to have two staff members
using the Hoyer lift. She confirmed Resident #4 had been using a Hoyer lift since admission because he
was unable to stand safely. She was asked how the staff would know the resident would need to be
transferred via Hoyer lift and she stated the resident would be care planned for it. She reviewed the plan of
care for Resident #4 and verified that the Hoyer lift was not included as intervention, but it should had been
included. She further stated she would add it immediately.
Resident #42:
On 7/21/25 at approximately 1:58 PM, an observation was made of resident #42 in her room sitting up in a
Geri-chair (a chair that reclines) with a Hoyer lift sling noted underneath the resident (a device used to
transfer the resident from bed to chair).
A review of Resident #42’s medical record revealed there was no physical or occupational therapy
evaluation for the use of a Geri-chair. Further review of the resident’s medical record revealed that
there was no physician order for the Geri-chair, nor a care plan for the use of the Geri-chair in the record.
On 7/22/25 at approximately 1:00 PM an interview was conducted with Staff Member F, a Certified Nursing
Assistant, (CNA) who indicated that she had been getting the resident up in a Geri-chair as long as the
resident had been in the facility and further indicated that she was not sure who made the decision that the
Geri-chair is appropriate for the residents. CNA F further indicated that she was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106140
If continuation sheet
Page 5 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106140
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pruitthealth - Southwood
2301 Bluff Oak Way
Tallahassee, FL 32311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
instructed to get the resident up today in a regular wheelchair.
Level of Harm - Minimal harm
or potential for actual harm
On 7/22/25 at approximately 1:15 PM an interview was conducted with Nurse G, Registered Nurse Unit
manager, and Nurse H, Licensed Practical Nurse. Both Nurse G and H confirmed that there was no care
plan, physician order, or therapy evaluation for the use of the Geri-Chair for resident #42.
Residents Affected - Few
On 7/22/25 at approximately 2:40 PM an interview was conducted with the Physical Therapist B, who
indicated that she did do an evaluation of resident #42 for wheelchair versus Geri-chair for positioning
today, and recommended that resident #42 was appropriate for wheelchair. The Physical therapist B further
indicated that she did not have resident #42 when she was on therapy case load, so she was not aware of
why the resident was in the Geri-chair, however she does tend to lean forward and to the side when the
resident is tired, so I did recommend that the resident be laid down for a rest period in bed when tired.
Resident #45:
On 7/22/25 at approximately 1:00 PM an observation was made of Resident #45 sitting in a Geri-chair in
the dayroom area of the 600 hall. Resident #45 stated “I wish they would let my legs down; I do not
like sitting like this.”
On 7/22/25 at approximately 1:10 PM an interview was conducted with CNA I, who indicated that Resident
#45 was in the Geri-chair because he keeps trying to get up and falls, and he messes with the other
residents, that the Geri-chair was for his safety.
On 7/22/25 at approximately 1:15 PM an interview was conducted with Nurse G, Registered Nurse Unit
manager, and Nurse H, Licensed Practical Nurse. Both Nurse G and H confirmed that there was no Care
plan, physician order, or therapy evaluation for the use of the Geri-Chair for Resident #45. Nurse H
indicated that the resident had been in the Geri-chair for the 3 weeks that Nurse H had been working at the
facility.
On 7/22/25 at approximately 2:15 PM, an observation was made of the resident being evaluated by the
Physical Therapist for a high back wheelchair. Resident #45 was observed to be able to propel himself
about the dayroom during the observation.
On 7/22/25 at approximately 2:40 PM an interview was conducted with the Physical Therapist, who
indicated that she did the evaluation of Resident #45. She recommended that the resident was appropriate
for the high back wheelchair instead of the Geri-chair and further indicated that the resident was able to
propel himself 10 feet during the evaluation. The Physical Therapist indicated that she was not sure why the
resident was in a Geri-chair.
On 7/22/25 at approximately 2:45 PM an interview was conducted with the Risk Manager (RM) and Director
of Nursing (DON) concerning the use of Geri-chairs for resident #42 and #45. Both the RM and DON
indicated that neither of them was aware that Geri-chairs could be considered a physical restraint. The RM
stated after contacting the regional nurse for the facility and confirming that the Geri-chair could be
considered a physical restraint, the residents were referred to therapy for an evaluation for positioning. The
DON indicated that it was her understanding that Resident #45 used the Geri-chair for comfort due to being
on hospice, but confirmed no documentation was available to indicate the reasoning for the Geri-chair. The
DON further indicated that they have started a performance improvement plan on the use of Geri-chairs
and that they make sure the staff are trained and that the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106140
If continuation sheet
Page 6 of 7
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106140
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pruitthealth - Southwood
2301 Bluff Oak Way
Tallahassee, FL 32311
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
residents receive evaluations for appropriate positioning.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106140
If continuation sheet
Page 7 of 7