Inspection Reports for Southern Hills Specialty Care
444 N W View Dr, Osceola, IA 50213, United States, IA, 50213
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 28, 2025, found the facility in substantial compliance with no deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to resident safety, abuse prevention, infection control, and food service practices. Several complaint investigations were substantiated over time, including issues with injury assessment, abuse prevention, and communication with family members, but fines or license actions were not listed in the available reports. The facility submitted multiple plans of correction that were accepted, and some prior deficiencies were corrected on re-inspection. The overall trend shows ongoing challenges with compliance in key areas, though recent findings indicate some improvement.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
A complaint investigation for complaint #2651491C was conducted on October 28, 2025.
Complaint Details
Complaint #2651491C was investigated and found to be unsubstantiated as the facility was in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 16, 2025
Visit Reason
This document is a plan of correction related to a previous inspection, indicating acceptance of the facility's substantial compliance and plan of correction.
Findings
The facility, Southern Hills Specialty Care, is certified in compliance effective August 25, 2025, based on acceptance of their credible allegation of substantial compliance and plan of correction.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and plan of correction.
Report Facts
Certification effective date: Compliance effective August 25, 2025
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted following a complaint regarding a staff member recording a resident without consent and sharing the video on social media, potentially violating resident rights and privacy.
Complaint Details
The complaint involved a video recorded by Staff G of Resident #73 without consent, shared with a degrading message on social media. Staff H received the video and reported it. Both staff were suspended pending investigation. The resident was unable to consent due to dementia. The investigation confirmed the violation of resident rights and facility policy.
Findings
The facility failed to provide a private space free from being recorded without consent and free from degrading treatment by staff for 1 of 3 residents reviewed. A video showing Resident #73 wandering was recorded and shared by staff with a degrading message, violating HIPAA and facility policy.
Deficiencies (1)
Failure to protect resident from being recorded without consent and from degrading treatment by staff.
Report Facts
Census: 86
Residents reviewed: 3
Date of video recording: Aug 8, 2025
Date of incident: Aug 11, 2025
Date of previous warning: Apr 28, 2025
Date of mandatory reporter training: Mar 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurse Aide (CNA) | Recorded and sent video of Resident #73 without consent; previously received a written warning; acknowledged wrongdoing |
| Staff H | Certified Nurse Aide (CNA) | Received video from Staff G, reported the incident to Assistant Director of Nursing |
| Staff I | Assistant Director of Nursing (ADON) | Received report from Staff H and notified Facility Administrator and Director of Nursing |
| Facility Administrator | Suspended Staff G and Staff H pending investigation; provided video evidence | |
| Director of Nursing (DON) | Director of Nursing | Received report regarding video; confirmed suspensions and investigation |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements related to resident care, safety, food service, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to protect residents from abuse and privacy violations, inadequate supervision and safety related to wheelchair foot pedals, unsanitary food serving practices with repeated deficiencies, ineffective quality assurance processes, and lapses in infection prevention and control practices including improper use of PPE and failure to disinfect equipment between residents.
Deficiencies (5)
Failed to provide a private space free from being recorded without consent and free from being degraded by staff members for 1 of 3 residents reviewed.
Failed to ensure foot pedals were applied to residents' wheelchairs during transport for 2 of 2 residents reviewed.
Failed to serve food in a manner that prevents cross contamination and promotes food hygiene.
Failed to ensure an effective process to address previously identified quality deficiencies, resulting in repeat sanitary food serving deficiencies.
Failed to disinfect a mechanical lift after use between residents, failed to don appropriate PPE during transfer, failed to maintain indwelling catheter bag below bladder, and failed to perform hand hygiene when moving from dirty to clean equipment.
Report Facts
Census: 86
Deficiencies cited: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurse Aide (CNA) | Named in abuse and privacy violation finding for recording and sharing video of Resident #73 |
| Staff H | Certified Nurse Aide (CNA) | Reported the abuse incident involving Staff G and Resident #73 |
| Staff I | Assistant Director of Nursing (ADON) | Received report from Staff H and reported to Facility Administrator and DON regarding abuse incident |
| Director of Nursing (DON) | Director of Nursing | Involved in suspension and investigation of abuse incident and acknowledged other deficiencies |
| Staff C | Certified Nurse Aide (CNA) | Observed transporting residents without foot pedals and commented on PPE use and equipment disinfection |
| Staff F | Certified Nurse Aide (CNA) | Observed transporting Resident #11 without foot pedals |
| Staff M | Certified Nurse Aide (CNA) | Observed cutting multiple residents' food with the same knife without sanitizing |
| Staff B | Certified Nurse Aide (CNA) | Interviewed about proper food handling and utensil use |
| Staff L | Licensed Practical Nurse | Interviewed about proper food handling and utensil use |
| Staff A | Certified Nurse Aide (CNA) | Observed failing to disinfect mechanical lift and improper PPE use during resident transfer |
| Staff D | Certified Nurse Aide (CNA) | Interviewed about PPE use and infection control |
| Staff E | Assistant Director of Nursing (ADON) and Infection Preventionist (IP) | Interviewed about infection control policies and equipment disinfection |
Inspection Report
Annual Inspection
Census: 86
Capacity: 86
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification and investigation of reported incidents and mandatory reports.
Findings
The facility was found to have multiple deficiencies including failure to prevent abuse and neglect, failure to ensure safety during wheelchair transport, food safety violations, inadequate infection control practices, and deficiencies in the Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (5)
Failure to provide a private space free from being recorded without consent, resulting in abuse.
Failure to ensure foot pedals were applied to wheelchairs during transport, risking resident safety.
Failure to serve food in a manner that prevents cross contamination and promotes food hygiene.
Failure to maintain an effective QAPI program addressing quality deficiencies.
Failure to establish and maintain an infection prevention and control program, including proper sanitizing and PPE use.
Report Facts
Census: 86
Deficiencies cited: 5
Audits planned: 4
Audits planned: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jimmy Bushong | Administrator | Facility Administrator named in relation to abuse investigation and corrective actions. |
| Staff H | Certified Nurse Aide (CNA) | Named in abuse incident involving recording a resident without consent. |
| Staff G | Certified Nurse Aide (CNA) | Named in abuse incident involving sending unauthorized video of resident. |
| Staff F | Certified Nurse Aide (CNA) | Observed transporting residents without foot pedals on wheelchairs. |
| Staff M | Certified Nurse Aide (CNA) | Observed cutting resident food with a rocker knife and cross contamination issues. |
| Staff I | Assistant Director of Nursing (ADON) | Reported abuse incident and involved in investigation. |
| Staff L | Licensed Practical Nurse (LPN) | Provided information on utensil use and cross contamination training. |
| Director of Nursing (DON) | Director of Nursing | Involved in abuse investigation and corrective action planning. |
Inspection Report
Census: 86
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to review the facility's pest control program following the discovery of a bed bug in a resident room on 2/19/25.
Findings
The facility failed to immediately shower residents, bag clothing and linens for laundering, and sanitize resident furniture after the discovery of a bed bug. The bed bug process was not initiated until two days after the bug was found, despite policy requirements.
Deficiencies (1)
Failure to immediately shower residents, bag clothing and linens for laundering, and sanitize resident furniture after discovery of a bed bug.
Report Facts
Residents Affected: Many
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Aide (CMA) | Reported discovery of bed bug and failure to follow bed bug process on 2/19/25 |
| Staff G | Certified Medication Aide (CMA) | Reported isolation of room and bagging of linens on 2/21/25 |
| Administrator | Acknowledged failure to follow bed bug process and described facility procedures |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as a result of complaints #126812-C and #127632-C and facility reported incident #125923-I between April 9, 2025 and April 10, 2025.
Complaint Details
Complaint #126812-C was substantiated.
Findings
The facility failed to maintain an effective pest control program as evidenced by the discovery of a bed bug in a resident room and failure to follow the bed bug process. Staff did not properly bag clothing or shower residents, and maintenance did not initiate the bed bug process timely.
Deficiencies (1)
Failure to maintain an effective pest control program resulting in bed bug infestation and inadequate response procedures.
Report Facts
Census: 86
Correction date: Correction date set for 4/11/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Bushong | Administrator | Signed as Administrator on the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The investigation was conducted in response to complaints #124395-C, #124408-C, #125413-C and a facility reported incident #125588-I from January 2, 2025 to January 7, 2025.
Complaint Details
Complaints #124395-C, #124408-C, #125413-C and facility reported incident #125588-I were investigated and found unsubstantiated.
Findings
The investigation found the allegations unsubstantiated and the facility in substantial compliance with applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 27, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance, and certification in compliance was granted effective September 27, 2024.
Inspection Report
Routine
Census: 85
Deficiencies: 3
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food handling and hygiene standards, specifically to assess if meals were served in a manner that protects residents from cross-contamination.
Findings
The facility failed to ensure proper hand hygiene and food handling during meal service, with staff observed touching resident food and not performing hand hygiene between assisting residents. Facility policies require hand hygiene and avoidance of direct contact with resident food, which were not followed.
Deficiencies (3)
Staff used ungloved fingers to move ice into a resident's drink.
Staff assisted multiple residents with eating without hand hygiene between residents and touched resident food with fingers.
Staff provided feeding assistance for two residents without hand hygiene between residents.
Report Facts
Census: 85
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of Complaints #122907-C and #123324-C and Facility Reported Incident 123323-I from September 9 to September 12, 2024.
Complaint Details
Complaints #122907-C and #123324-C and Facility Reported Incident 123323-I were investigated and found to be unsubstantiated.
Findings
The facility failed to serve meals in a manner that protects residents from cross-contamination, including staff not using hand hygiene between residents and touching resident food directly. Complaints and the facility reported incident were unsubstantiated.
Deficiencies (1)
Failure to serve meals in a manner that protects residents from cross-contamination, including staff using ungloved fingers to handle ice and not performing hand hygiene between residents during feeding assistance.
Report Facts
Census: 85
Audits: 4
Audits: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Restorative Aide (RA) | Observed using ungloved fingers to move ice into resident's drink |
| Staff B | Certified Nurse's Aide (CNA) | Observed assisting residents with eating without hand hygiene and touching resident food |
| Staff C | Certified Nurse's Aide (CNA) | Observed providing feeding assistance without hand hygiene between residents |
| Staff D | Interviewed regarding policy on nursing staff touching resident food | |
| Staff E | Registered Nurse (RN) | Interviewed regarding hand hygiene and food handling policies |
| Carla Mahler | Regional Director of Operations | Signed the plan of correction |
| Director of Nursing | Interviewed regarding nursing staff expectations for feeding assistance and food handling |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 18, 2024
Visit Reason
A revisit of the survey ending June 7, 2024 and investigation of complaint #121759-C was conducted from August 16 to August 18, 2024.
Complaint Details
Investigation of complaint #121759-C was conducted during the revisit.
Findings
All deficiencies identified in the prior survey were corrected and the facility was found to be in substantial compliance effective June 8, 2024.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 2, 2024
Visit Reason
The inspection was conducted as a routine annual survey of Southern Hills Specialty Care to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 2, 2024
Visit Reason
An annual recertification survey and investigation of facility reported incidents #118775-I and #120376-I were conducted from April 29, 2024 to May 2, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
A complaint investigation for complaints #118042-C and #118151-C was conducted from January 16, 2024 to January 18, 2024.
Complaint Details
Investigation was related to complaints #118042-C and #118151-C; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 30, 2023
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, resulting in certification of compliance effective December 30, 2023.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted and accepted by the surveyors.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Dec 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to identify and assess an injury (a large bruise) on Resident #6 in a timely manner.
Complaint Details
The visit was complaint-related due to the facility's failure to timely identify and assess a bruise on Resident #6. The bruise was found to be related to a fall on 11/6/23 but was not documented or reported until 11/19/23. Staff statements revealed lack of reporting and follow-up. The complaint was substantiated with findings of minimal harm and few residents affected.
Findings
The facility failed to identify and assess a large bruise on Resident #6's upper left arm at the time it occurred. The bruise was discovered over a week after a fall, and staff did not report or document it promptly. The facility acknowledged past non-compliance and has initiated new skin check procedures and staff education to prevent recurrence.
Deficiencies (1)
Failure to identify and assess an injury (large bruise) on Resident #6 at the time it occurred.
Report Facts
Bruise measurement length: 13.39
Bruise measurement width: 5.92
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Provided statement about Resident #6's care and reporting practices related to the bruise |
| Staff B | Certified Nurse Aide (CNA) | Provided statement and showered Resident #6; noticed bruise but did not report it further |
| Staff C | Licensed Practical Nurse (LPN) | Noticed bruise on Resident #6, took a picture, and reported to Nurse Manager |
| Regional Director of Clinical Services | Acknowledged past non-compliance and described new skin check procedures | |
| Director of Nursing (DON) | Acknowledged past non-compliance and described new skin check procedures and staff education |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Dec 12, 2023
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#115070-C, #115399-C, #115617-C, #117233-C) and facility-reported incidents (#115575-I, #115731-I, #116304-I, #117230-I, #117051-I) from December 5, 2023 to December 12, 2023. Several complaints and one incident were substantiated.
Complaint Details
Complaints #115399-C, #115617-C, and #117233-C were substantiated. Facility reported incident #117230-I was substantiated. The investigation found failure to timely identify and assess a bruise on Resident #6 following a fall.
Findings
The facility failed to identify and assess a large bruise on Resident #6's upper left arm in a timely manner. The bruise was discovered over a week after a fall incident, and staff did not report or document it promptly despite multiple opportunities. The facility acknowledged past non-compliance and implemented new weekly skin check procedures and staff education to prevent recurrence.
Deficiencies (1)
Failure to identify and assess an injury (bruise) on Resident #6 in a timely manner.
Report Facts
Resident census: 80
Bruise size: 13.39
Bruise size: 5.92
BIMS score: 3
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as an investigation of Complaints #113807-C, #114574-C, and Facility Reported Incidents #109134-I and #110364-I from August 7 to August 9, 2023.
Complaint Details
Complaint #113807-C and #114574-C were substantiated. The investigation found that Resident #7's family was not informed when the Medical Director completed the 60 day evaluation instead of the attending physician due to scheduling issues.
Findings
The facility failed to notify a family representative about a physician used to complete a 60-day evaluation for one resident, Resident #7. The Medical Director completed the evaluation timely when the attending physician was unable to do so within the required timeframe, but the family was not informed of this change.
Deficiencies (1)
Failure to notify a family representative of a physician used to complete a 60 day evaluation for Resident #7.
Report Facts
Resident census: 83
Complaints investigated: 2
Facility Reported Incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Assistant Director of Nursing | Monitored compliance with physician visits and reported on the physician evaluation process for Resident #7 |
| Staff B | Unit Manager and Registered Nurse | Provided information about the physician evaluation timeline and communication with family for Resident #7 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
The document is a plan of correction acceptance indicating the facility will be certified as in compliance effective January 5, 2023.
Findings
The facility submitted a plan of correction which was accepted, resulting in certification of compliance effective January 5, 2023. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 11
Date: Nov 22, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint 109018-C, including reported incidents 108811-1 and 109016-1.
Complaint Details
Complaint 109018-C and facility reported incidents 108811-1 and 109016-1 were substantiated.
Findings
The facility was found to have multiple deficiencies related to resident rights, exercise of rights, freedom from abuse and neglect, comprehensive care planning, sufficient nursing staff, infection control, and other regulatory requirements. Several residents were identified as affected by these deficiencies, and corrective actions and plans of correction were outlined.
Deficiencies (11)
Failure to maintain resident dignity for 2 of 18 residents reviewed.
Failure to maintain accurate records related to Cardiopulmonary Resuscitation (CPR) status for 1 of 16 residents reviewed.
Failure to implement adequate nursing interventions to prevent inappropriate resident-to-resident behavior for 1 of 7 residents reviewed.
Failure to submit a significant change review for Pre-Admission Screening and Resident Review (PASRR) for 1 of 2 residents reviewed.
Failure to implement adequate nursing interventions to prevent abuse and neglect for 1 of 7 residents reviewed.
Failure to revise care plan related to oxygen use for 1 of 18 residents reviewed.
Failure to prevent a resident from eloping and to respond adequately to door alarms for 1 resident.
Failure to ensure timely physician visits for 3 of 85 residents reviewed.
Failure to assure call lights are within resident reach and respond timely for 1 of 18 residents reviewed.
Failure to follow professional standards for food service safety, including storage and preparation.
Failure to establish and maintain an infection prevention and control program.
Report Facts
Residents reviewed: 18
Residents reviewed: 16
Residents reviewed: 7
Residents reviewed: 2
Residents reviewed: 85
Residents reviewed: 1
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Certified Nursing Assistant (CNA) | Named in resident dignity deficiency related to assistance and behavior. |
| Staff J | Certified Medication Aide (CMA) | Named in resident dignity deficiency related to call light response and assistance. |
| Administrator | Reported expectations for staff to treat residents with dignity and respect. | |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for staff and involved in care plan and incident investigations. |
| Staff F | Certified Nursing Assistant (CNA) | Involved in cardiac arrest code status review. |
| Staff G | Registered Nurse (RN) | Involved in cardiac arrest code status review. |
| Staff H | RN Staff | Involved in cardiac arrest code status review. |
| Staff A | Licensed Practical Nurse (LPN) | Reported on resident behavior and alarm response. |
| Staff D | Certified Nursing Assistant (CNA) | Reported on resident behavior and alarm response. |
| Staff C | Certified Nursing Assistant (CNA) | Reported on resident party and alarm response. |
| Staff I | Social Services Director | Interviewed regarding PASRR submissions. |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food safety and storage. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 14, 2022
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of a credible allegation of compliance and certification of the facility effective 10/13/2022.
Findings
The facility was certified in compliance based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Sep 14, 2022
Visit Reason
The inspection was conducted due to investigation of facility-reported incidents #103672-I and #107266-I and complaint #107335-C between September 1 and September 14, 2022.
Complaint Details
Complaint #107335-C was substantiated. Facility-reported incidents #103672-I and #107266-I were not substantiated.
Findings
The facility failed to serve coffee free of a soapy/chemical taste during supper on 8/28/22 for 32 residents, resulting in adverse consequences for one resident. The complaint was substantiated, and the facility took corrective actions including educating dietary staff and monitoring cleaning procedures.
Deficiencies (1)
Failure to serve coffee free of a soapy/chemical taste during supper on 8/28/22 affecting 32 residents.
Report Facts
Residents affected: 32
Current census: 88
Residents consuming coffee during supper: 25
Residents consuming coffee during supper: 18
Residents consuming coffee during supper: 14
Cleaning cycle time: 7
Cleaning rinse repetitions: 4
Cleaning rinse repetitions: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Authored nursing note documenting resident symptoms and emergency response |
| Director of Nursing | Director of Nursing (DON) | Authored nursing note and conducted interviews related to coffee incident |
| Dietary Services Manager | Dietary Services Manager | Educated employees on coffee machine cleaning and monitored compliance |
| Staff B | Certified Nursing Assistant (CNA) | Reported coffee taste complaints and participated in interviews |
| Staff C | Dietary Aide | Interviewed regarding coffee taste and cleaning procedures |
| Staff D | Dietary Staff | Interviewed regarding coffee machine cleaning and coffee taste |
| Staff E | Cook/Dietary Aide | Interviewed regarding coffee machine cleaning and coffee taste |
| Staff F | Cook/Dietary Aide | Interviewed regarding coffee machine cleaning and coffee taste |
Inspection Report
Annual Inspection
Census: 85
Capacity: 85
Deficiencies: 8
Date: May 13, 2021
Visit Reason
The inspection was conducted as part of the annual recertification and State Licensure Survey for Southern Hills Specialty Care.
Findings
The facility was found deficient in multiple areas including quality of care related to monitoring residents with congestive heart failure, prevention and treatment of pressure ulcers, restorative nursing programs, sufficient nursing staff, pharmacy services, medication storage and administration, food procurement and sanitation, and infection control. Several residents were identified as at risk or affected by these deficiencies.
Deficiencies (8)
Failure to monitor and implement interventions for residents with congestive heart failure, including weight monitoring and physician notification.
Failure to provide necessary treatment and services to prevent pressure ulcers, including inadequate skin assessments and documentation.
Failure to provide a restorative nursing program for residents with limited mobility.
Insufficient nursing staff to provide care and respond to call lights in a timely manner.
Failure to provide routine and emergency pharmacy services and maintain accurate medication records.
Failure to maintain accurate controlled substance records and medication storage.
Failure to properly store and label food items and maintain food safety standards.
Failure to implement and maintain infection prevention and control program, including catheter care and isolation procedures.
Report Facts
Census: 85
Deficiencies cited: 8
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Date: Feb 2, 2021
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey and investigation of facility reported incidents and complaints conducted by the Department of Inspection and Appeals from January 11 to February 2, 2021.
Complaint Details
Facility reported incident 91996-I was substantiated. Complaint 93157-C was not substantiated. Facility reported incidents 90186-I and 90712-I were not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. However, deficiencies were found related to abuse and neglect, including failure to prevent staff from slapping a resident and failure to immediately report allegations of abuse for two residents. The facility reported a census of 82 residents.
Deficiencies (2)
Facility failed to prevent staff from slapping a resident during care.
Facility failed to immediately report allegations of abuse for 2 residents.
Report Facts
Total residents: 82
Correction date: Correction date noted as 2-7-21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in abuse incident where she slapped Resident #1 and was terminated on 5/13/20 |
| Staff D | Nurse Manager | Nurse manager on call during abuse incident on 5/8/20 |
Inspection Report
Routine
Census: 89
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #90420-C was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #90420-C was unsubstantiated.
Report Facts
Total residents: 89
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Jan 29, 2020
Visit Reason
Complaints 86290-C and 86555-C were investigated from January 27 to 29, 2020. The investigation was triggered by allegations related to quality of care.
Complaint Details
Complaint 88290-C and Complaint 86555-C were substantiated based on the investigation findings.
Findings
The facility failed to provide catheter care in accordance with professional standards, resulting in a resident (Resident #1) having an indwelling catheter left unchanged for over 8 months, leading to a genitourinary infection. The facility did not reschedule a missed urology appointment and lacked clear catheter care protocols.
Deficiencies (1)
Failure to provide catheter care in accordance with professional standards, including not changing the catheter as ordered and missing follow-up appointments.
Report Facts
Census: 88
Duration catheter not changed: 8
Antibiotic treatment duration: 7
Catheter change frequency order: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Documented assessment of Resident #1 with swelling and infection signs. |
| Staff B | Licensed Practical Nurse | Documented progress notes regarding infection symptoms and communications with urologist and primary care physician. |
| Staff C | Licensed Practical Nurse | Documented catheter change arrangements with hospital. |
| Nurse Consultant | Nurse Consultant | Provided explanation of Resident #1's catheter history and facility confusion about follow-up. |
| Resident #1's Primary Care Physician | Primary Care Physician | Interviewed regarding catheter change frequency and infection. |
| Resident #1's Urologist | Urologist | Interviewed regarding catheter change frequency and expressed surprise at prolonged catheter use without infection. |
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