Southern Hills Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Southern Hills Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 15, 2025

  1. On 04/21/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to supervise residents with exit seeking behaviors. On 04/14/25 Resident #14 was observed to leave the courtyard by a resident, from an unlocked gate, staff were notified and were able to redirect Resident #14 back into the building. Based on record review and interview, the facility failed to provide supervision for 1 (#14) of 1 sampled resident reviewed for exit seeking behaviors. The DON identified 66 residents resided at the facility. Findings: An elopement evaluation, dated 03/27/25, showed Resident #14 was at risk for elopement. […]

• Actual harm, isolatedF659Jul 3, 2026

  Based on interview, record review, and facility document and policy review, the facility failed to ensure only licensed qualified staff replaced a resident's indwelling urinary catheter for 1 (Resident #26) of 1 resident reviewed for urinary catheters. Specifically, Certified Medication Aide (CMA) #2, under the direct supervision of Registered Nurse (RN) #1, attempted to replace Resident #26's indwelling urinary catheter. As a result, Resident #26 experienced pain, bleeding from the insertion site, and bloody urine with clots.Findings included: A facility policy titled, Catheter Care, with a copyright date of 2024, indicated, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy… […]

• Actual harm, isolatedF689Jul 3, 2026

  Based on facility policy review, facility document review, record review, and interview, the facility failed to provide adequate supervision and assistance to prevent accidents for 1 (Resident #91) of 7 residents reviewed for accidents. Specifically, on 04/01/2026, Licensed Practical Nurse (LPN) #19 turned Resident #91 in bed by herself instead of utilizing two people as per the resident's care plan, which resulted in Resident #91 hitting their head on the wall, causing injury.Findings included: An undated facility policy titled, Accident Prevention & [and] Hazard Mitigation, indicated, the Purpose & Objective was To establish operational guidelines that maintain a resident environment as free from accident hazards as is reasonably practicable, and to provide individualized supervision and… […]

• Actual harm, isolatedF690Jul 3, 2026

  Based on interview, record review, and facility document and policy review, the facility failed to provide appropriate care and services to a resident with an indwelling urinary catheter for 1 (Resident #26) of 1 resident reviewed for urinary catheters. Certified Medication Aide (CMA) #2, an unlicensed staff member, replaced Resident #26's indwelling urinary catheter while under the direct supervision of Registered Nurse (RN) #1. CMA #2 inserted the indwelling urinary catheter into Resident #26 and inflated the catheter balloon prior to seeing a return of urine. RN #1 then took over the insertion of Resident #26's indwelling urinary catheter procedure, deflated the balloon, repositioned the catheter, and reinflated the balloon, with no observed return of urine. […]

• No harm, potential for more than minimal, widespreadF814Jul 3, 2026

  Based on facility policy review, observation, and interview, the facility failed to ensure refuse was properly contained in dumpsters and failed to ensure outside dumpster lids and side accessibility sliders were operational and remained closed to reduce the potential for harboring insects or rodents for 2 of 2 dumpsters observed. The failures had the potential to affect all the residents in the facility.Findings included: A facility policy titled, General Refuse, Trash & Dumpster Management, effective 03/03/2026, revealed, 3. Outside Dumpster Area Operational Standards, which revealed, The physical dumpster containers and surrounding enclosures must be maintained in accordance with the following criteria, which included 1. […]