Inspection Reports for Southern Hills Specialty Care
444 N W View Dr, Osceola, IA 50213, United States, IA, 50213
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Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 28, 2025
Visit Reason
A complaint investigation for complaint #2651491C was conducted on October 28, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #2651491C was investigated and found to be unsubstantiated as the facility was in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 1
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)
| Description |
|---|
| 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
Annual Inspection
Census: 86
Capacity: 86
Deficiencies: 5
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.
Severity Breakdown
D: 3
E: 1
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide a private space free from being recorded without consent, resulting in abuse. | D |
| Failure to ensure foot pedals were applied to wheelchairs during transport, risking resident safety. | D |
| Failure to serve food in a manner that prevents cross contamination and promotes food hygiene. | E |
| Failure to maintain an effective QAPI program addressing quality deficiencies. | F |
| Failure to establish and maintain an infection prevention and control program, including proper sanitizing and PPE use. | D |
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
Complaint Investigation
Census: 86
Deficiencies: 1
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.
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.
Complaint Details
Complaint #126812-C was substantiated.
Deficiencies (1)
| Description |
|---|
| 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
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.
Findings
The investigation found the allegations unsubstantiated and the facility in substantial compliance with applicable regulations.
Complaint Details
Complaints #124395-C, #124408-C, #125413-C and facility reported incident #125588-I were investigated and found unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
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
Annual Inspection
Census: 85
Deficiencies: 1
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.
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.
Complaint Details
Complaints #122907-C and #123324-C and Facility Reported Incident 123323-I were investigated and found to be unsubstantiated.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | SS=E |
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
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.
Findings
All deficiencies identified in the prior survey were corrected and the facility was found to be in substantial compliance effective June 8, 2024.
Complaint Details
Investigation of complaint #121759-C was conducted during the revisit.
Inspection Report
Annual Inspection
Deficiencies: 0
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
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.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaints #118042-C and #118151-C; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
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
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.
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.
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to identify and assess an injury (bruise) on Resident #6 in a timely manner. | SS=D |
Report Facts
Resident census: 80
Bruise size: 13.39
Bruise size: 5.92
BIMS score: 3
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
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.
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.
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.
Deficiencies (1)
| Description |
|---|
| 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
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
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.
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.
Complaint Details
Complaint 109018-C and facility reported incidents 108811-1 and 109016-1 were substantiated.
Deficiencies (11)
| Description |
|---|
| 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
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
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.
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.
Complaint Details
Complaint #107335-C was substantiated. Facility-reported incidents #103672-I and #107266-I were not substantiated.
Deficiencies (1)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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
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.
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.
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.
Severity Breakdown
Level 3: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to prevent staff from slapping a resident during care. | Level 3 |
| Facility failed to immediately report allegations of abuse for 2 residents. | Level 3 |
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
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.
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.
Complaint Details
Complaint #90420-C was investigated and found to be unsubstantiated.
Report Facts
Total residents: 89
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
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.
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.
Complaint Details
Complaint 88290-C and Complaint 86555-C were substantiated based on the investigation findings.
Severity Breakdown
S: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide catheter care in accordance with professional standards, including not changing the catheter as ordered and missing follow-up appointments. | S |
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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