Inspection Reports for
Southern Hills Specialty Care

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.

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.

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.

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.

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.

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.

Complaint #126812-C was substantiated.

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.

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.

Complaints #122907-C and #123324-C and Facility Reported Incident 123323-I were investigated and found to be unsubstantiated.

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.

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.

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.

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.

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 #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.

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 109018-C and facility reported incidents 108811-1 and 109016-1 were substantiated.

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 #107335-C was substantiated. Facility-reported incidents #103672-I and #107266-I were not substantiated.

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.

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.

Facility reported incident 91996-I was substantiated. Complaint 93157-C was not substantiated. Facility reported incidents 90186-I and 90712-I were not substantiated.

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 88290-C and Complaint 86555-C were substantiated based on the investigation 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.