Southern Hills Specialty Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 22, 2022

  Based on observation, record review and staff interviews, the facility failed to prevent a resident that exhibited signs of cognitive impairment from eloping from the facility. Elopement means a resident that leaves the facility without staff knowledge or permission. On 10/29/22, staff failed to thoroughly investigate when the front door alarm had been activated. Resident #14 eloped and was found a quarter mile from the facility on the side of the road, near the entrance to the interstate. The resident wore a wanderguard alarm that failed to work properly at the front door. These findings constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 84 residents. […]

• Actual harm, isolatedF686May 13, 2021

  Based on observation, clinical record review and staff and resident interviews, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 residents reviewed (Resident #14). The facility reported a census of 85 residents. Findings include: The Minimum Data Set (MDS) assessment tool defines pressure ulcer stages as follows: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• No harm, potential for more than minimal, widespreadF865Aug 21, 2025

  Based on review of Certification and Survey Provider Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), staff interview, and review of the facility QAPI (Quality Assurance Performance Improvement) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. This resulted in the facility receiving a Sanitary food serving deficiency for the third consecutive recertification survey. The facility reported a census of 86 residents. Findings Include:The CASPER report, dated 08/13/2025, documented the facility had been cited by the Iowa Department of Inspections, Appeals, and Licensing for failures to serve food in a sanitary manner, resulting in an F0812 deficiency, twice in 2024. […]

• No harm, potential for more than minimal, patternF812Aug 21, 2025

  Based on direct observation, staff interview, and facility document review, the facility failed to serve food in a manner that prevents cross contamination and promotes food hygiene. The facility reported a census of 86. Findings include: A direct observation of the lunch meal on 08/19/2025 at 12:39 PM revealed Staff M, Certified Nurse Aide (CNA), take a crescent shaped rocker style knife from the dining cart and cut the food of several residents. During the observation, after cutting the first resident's food, she cut the food of Resident #2 after the resident had begun to touch and cut her own food. The resident was observed licking her finger and touching her food before Staff M, CNA, used the rocker knife to cut her food. […]

• No harm, potential for more than minimal, patternF812Sep 12, 2024

  Based on direct observation, staff interview, and facility document review, the facility failed to serve meals in a manner that protects residents from cross-contamination. The facility reported a census of 85. Findings include: A direct observation of the lunch meal on 09/09/24 at 12:26 PM revealed Staff A, Restorative Aide (RA), used her ungloved fingers and hand to move ice from a Styrofoam cup into a resident's drink when the resident requested ice in his drink. A direct observation of the lunch meal on 09/09/24 at 01:08 PM in which Staff B, Certified Nurse's Aide (CNA), assisted three separate residents with eating without using hand hygiene in between each resident. During the same meal observation she served three meals with her fingers touching resident's food. […]