Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southern Oaks Care Center during CMS and state inspections, most recent first.
A resident with dementia and depression, who was moderately cognitively impaired, frequently refused showers, became agitated or aggressive when asked to bathe or get out of bed, and sometimes would not allow staff to change incontinence briefs, as reported by multiple CNAs and an LPN. Staff documented these refusals and behaviors in progress notes and behavior notes, including an episode of aggression related to showering, but no ongoing interventions or preventive strategies were identified in the behavior documentation. The resident’s comprehensive care plan did not include interventions for these behavioral symptoms or shower refusals, despite the pattern of behavior and staff awareness, and the MDS coordinator acknowledged that these behaviors should have been included in the care plan.
A resident with HTN, COPD, hyperlipidemia, and renal insufficiency was discharged to an inpatient rehab facility, but the chart did not contain a discharge summary. The resident had moderately impaired cognition with a BIMS score of 10, and MDS staff confirmed that no discharge summary had been completed.
Failure to complete discharge assessment for a resident who was discharged home against medical advice. The resident had an entry assessment and a Medicare 5-day assessment completed, but the chart did not show a discharge assessment, and MDS staff stated one should have been completed.
Failure to complete a baseline care plan within 48 hours of admission. A resident was observed in bed and stated he had been in the facility for a few weeks. Record review and DON interview showed the resident did not have a 48-hour care plan until several days after admission, despite facility policy requiring a baseline plan of care to meet immediate needs within 48 hours.
A resident with diagnoses including urinary retention, acute kidney failure, and BPH was observed with an indwelling catheter and drainage bag attached to a wheelchair. The chart documented the catheter in the admission assessment and care plan, but no physician order for the catheter was found in the record, and the DON stated an order should have been present.
A resident receiving nebulizer treatments for chronic bronchitis and acute respiratory failure with hypoxia had the nebulizer mask and tubing observed lying on a sheeted mattress behind the recliner on multiple occasions. The record had no documented mask or tubing changes, and staff stated the equipment was not stored properly, should have been kept in a sealed plastic bag, and was not labeled or dated to show when it was last changed.
Failure to Address Consultant Pharmacist Recommendation: The facility failed to ensure a physician addressed a consultant pharmacist’s recommendation for a resident with schizophrenia, anxiety, and depressive disorders. The pharmacist suggested a trial reduction of Sertraline from 100 mg daily to 50 mg daily, but the report was not answered within the expected timeframe, and the DON stated the physician should have responded within 30 days.
Oxygen tubing was not maintained in a sanitary manner for a resident with PVD and dementia. Staff observed the tubing lying on the floor next to the bed and later on the floor while the resident sat in a wheelchair. The resident stated staff did not place the tubing in a plastic bag, and the IP stated oxygen tubing should be stored off the floor in a plastic bag on the wall.
The facility failed to ensure proper medication administration, as staff did not remain with residents until medications were taken, and medications were not administered as ordered for two residents. Medications were left unsupervised on dining tables, and some medications were unavailable, leading to missed doses.
A resident with dementia and hemiplegia fell and sustained a head laceration, but the quarterly assessment inaccurately recorded the fall as without injury. The DON noted the MDS Coordinator relied on an incorrect fall report and did not review progress notes.
The facility failed to report an alleged sexual abuse incident involving a resident to the appropriate authorities within the required timeframe. The incident was not reported to the Oklahoma State Department of Health, Adult Protective Services, the police, and the Nurse Aide Registry within the stipulated time, as required by the facility's policy. The corporate nurse confirmed the noncompliance, identifying a significant deficiency in the facility's handling of the incident.
The facility did not follow its food temperature monitoring policy, as temperatures for meals were not documented, affecting food quality. A resident with heart failure reported cold food, and a cook admitted to not recording temperatures, confirmed by the CDM.
Failure to Care Plan Behavioral Symptoms and Hygiene Refusals
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with measurable interventions addressing behavioral symptoms for a resident with dementia and depression. On observation, the resident was noted sitting in a chair beside the bed with a strong urine odor in the room. The admission form documented diagnoses of dementia and depression, and a quarterly assessment showed the resident was moderately impaired in cognition with a BIMS score of 11. Despite this, the care plan dated 05/28/25 did not include interventions for behaviors, including agitation and refusal of showers. Behavior documentation dated 02/26/26 described the resident as aggressive when asked about showers, with behavior worsening when asked to get up from sleep. The note indicated non-pharmacological attempts such as explaining the importance of a shower, but listed no results or interventions to prevent recurrence, and showed that the physician and family were not notified. Multiple CNAs and an LPN reported that the resident frequently refused showers, became agitated or hateful when asked, sometimes would not get out of bed or allow staff to change briefs, and that refusals were reported to the charge nurse and documented in progress notes. The MDS coordinator acknowledged that the resident’s agitation and refusal of showers were not reflected in the care plan and stated that these behaviors should have been care planned.
Missing Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to complete a discharge summary for 1 of 2 sampled residents reviewed for discharges. Resident #64 was admitted with diagnoses of hypertension, chronic obstructive pulmonary disease, hyperlipidemia, and renal insufficiency. A quarterly assessment dated 11/05/25 showed the resident had moderately impaired cognition with a BIMS score of 10. A discharge assessment showed the resident was discharged to an inpatient rehab facility on 12/26/25, but a review of the chart did not show a discharge summary. On 03/19/26 at 3:07 p.m., the MDS staff member stated that no discharge summary had been completed.
Failure to Complete Discharge Assessment
Penalty
Summary
The facility failed to ensure a discharge assessment was completed for one resident reviewed for resident assessments. The resident was admitted to the facility, then discharged home against medical advice the next day. An entry assessment was completed and submitted two days later, and a Medicare 5-day assessment was completed several days after that. However, a review of the resident's chart did not show that a discharge assessment had been completed. During interview, the MDS staff stated that a discharge assessment should have been completed.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed for Resident #32 within 48 hours of admission. Record review showed the resident was admitted to the facility and that a Care Plan Report dated 03/15/26 indicated the baseline care plan was initiated on 03/15/26. However, the facility policy titled, Care Plans - Baseline, stated that a baseline plan of care to meet the resident's immediate needs shall be developed within 48 hours of admission. During observation on 03/17/26 at 11:51 a.m., Resident #32 was seen in bed and stated he had been in the facility for a few weeks. On 03/20/26 at 10:04 a.m., the DON stated the resident was admitted on [DATE] and did not have a 48 hour care plan until 03/15/26.
Missing Physician Order for Indwelling Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling catheter for Resident #55, who was one of one sampled resident reviewed for catheters. The resident was observed on 03/17/26 sitting in a wheelchair in the dining room with the catheter bag attached to the side of the wheelchair in a privacy bag, and on 03/18/26 sitting in a wheelchair in the room with the catheter hanging on the side of the wheelchair draining to gravity, with the bag inside a privacy bag. The resident's record showed diagnoses including retention of urine, acute kidney failure, and benign prostatic hyperplasia. An admission assessment dated 02/15/26 documented that the resident had an indwelling catheter, and a care plan revised 02/20/26 also showed the resident had an indwelling catheter. However, the record did not contain a physician's order for the catheter, and on 03/19/2026 the DON stated there should have been a physician order for the catheter.
Nebulizer Equipment Not Stored or Documented Properly
Penalty
Summary
The facility failed to change and store nebulizer tubing in a sanitary manner for one resident who was reviewed for respiratory care. Res #4 was observed on three separate occasions with a nebulizer mask and tubing lying on a sheeted bed mattress directly behind the resident's recliner. The resident had diagnoses that included simple chronic bronchitis and acute respiratory failure with hypoxia, and a physician order dated 02/04/26 directed budesonide 0.5 mg/2 milliliters via nebulizer once daily for shortness of breath. The admission assessment showed the resident was moderately cognitively impaired with a BIMS score of 12 and received respiratory therapy. The medical record contained no documented nebulizer mask or tubing changes. When interviewed, Res #4 stated they had received breathing treatments intermittently and were unsure whether they had received one that day or that morning. LPN #1 stated the nebulizer equipment was not stored properly and said it should have been stored in a sealed plastic bag after use. LPN #1 was also unsure when the mask and tubing had last been changed because the tubing had not been labeled and dated. The IP stated the nebulizer equipment should have been stored in a plastic bag for infection control, and the ADON stated the tubing should have been documented as changed in a progress note or on the treatment administration record.
Failure to Address Consultant Pharmacist Recommendation
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents reviewed for unnecessary medications. Resident #3 had diagnoses including schizophrenia, anxiety, and depressive disorders. The Consolidated Report from the Consultant Pharmacist, dated 11/05/25, stated that Sertraline 100 mg daily could be trialed at a reduced dose of 50 mg daily, but the consultant pharmacist report was not addressed by the physician. On 03/19/26 at 3:15 p.m., the DON stated that the physician should have answered the report within 30 days.
Oxygen Tubing Stored on the Floor
Penalty
Summary
The facility failed to ensure oxygen tubing was maintained in a sanitary manner for Resident #19. On 03/18/26, the resident was observed not using oxygen, and the oxygen tubing was lying on the floor next to the bed. On 03/19/26, the resident was again observed sitting in a wheelchair watching television, with the oxygen tubing lying on the floor. The resident’s record showed diagnoses including peripheral vascular disease and dementia, and a quarterly assessment dated 12/18/25 showed the resident was cognitively intact with a BIMS score of 13. The facility policy titled Oxygen Administration stated that oxygen cannula and tubing used PRN should be stored in a clean manner off the floor. The resident stated on 03/19/26 that staff did not put the oxygen tubing in a plastic bag, and on 03/20/26 the infection preventionist stated oxygen tubing should not be on the floor and should be stored in a plastic bag on the wall.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that staff remained with residents until medications were taken, as observed with four residents. During breakfast, medication cups containing medications were left on the dining tables next to the residents' breakfast trays. The residents were observed to take their medications at their own discretion, without staff supervision, and without physician orders to self-administer medications. This was contrary to the facility's policy, which required staff to remain with residents until all medications were taken. Additionally, the facility failed to administer medications as ordered for two residents. One resident with hypertension had a physician's order for Hydralazine HCI 25 mg three times a day, but the medication administration record indicated that the medication was not consistently administered, with a '9' noted on several occasions without documentation. Another resident with a fractured left femur and chronic pain had a physician's order for Tylenol 325 mg, but the medication was not available in the required strength, leading to missed doses as indicated by the '9' on the medication administration record.
Inaccurate Resident Assessment Related to Falls
Penalty
Summary
The facility failed to ensure an accurate resident assessment related to falls for one of the residents. The resident, who had diagnoses including dementia, weakness, lack of coordination, and hemiplegia/hemiparesis following a cerebral infarction, experienced a fall in their room, resulting in a laceration to the left side of their head. This incident occurred on 06/17/24, and the resident was sent to the hospital for evaluation. However, the quarterly resident assessment dated 07/16/24 inaccurately documented that the resident had one fall without injury since the last assessment. The Director of Nursing (DON) later reported that the Minimum Data Set (MDS) should have documented a fall with injury. The inaccuracy was attributed to the MDS Coordinator relying on an incorrect fall report and failing to review the progress notes.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving a resident to the appropriate authorities within the required timeframe. According to the facility's Abuse Investigation and Reporting policy, any alleged violations involving abuse must be reported immediately, but no later than two hours if the alleged violation involves abuse. However, the incident, which was reported to the Administrator on the same day it occurred, was not reported to the Oklahoma State Department of Health (OSDH), Adult Protective Services (APS), the police, and the Nurse Aide Registry within the stipulated time. The OSDH 283 Incident Report Form was sent by fax two days later, and the Nurse Aide Registry was notified even later, four days after the incident. The corporate nurse confirmed that the facility's policy was not followed, as the Administrator did not report the incident timely to the required authorities. The report also noted that the Nurse Aide Registry should have been notified within 24 hours, but this was delayed. The failure to report promptly was identified as noncompliance with the facility's policy and regulatory requirements, highlighting a significant deficiency in the facility's handling of the alleged abuse incident.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to adhere to its food temperature monitoring policy during a kitchen observation, which affected the quality of food served to residents. The policy required that food temperatures be recorded on a Food Temperature Chart at the beginning of the tray line, and corrective actions be taken if temperatures were not within acceptable ranges. However, during the observation, it was found that the temperatures for breakfast and lunch services were not documented as required. A cook admitted to keeping the temperatures in their head instead of recording them, which was confirmed by the Certified Dietary Manager (CDM) who stated that without documentation, temperature monitoring did not occur. Resident #2, who had diagnoses including heart failure and unspecified cerebral infarction, reported that food was served cold in the dining room, prompting them to eat in their room. This resident's quarterly MDS assessment indicated intact cognition, suggesting they were aware of the food temperature issue. The lack of proper documentation and adherence to the facility's policy led to a deficiency in ensuring food safety and palatability for the residents receiving nutrition from the kitchen.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pawnee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairfax Behavioral Health & Memory Care Community | 17 mi | ★★★★★ | 4 | 0 |
| Cleveland Care And Rehab Center | 18.7 mi | ★★★★★ | 4 | 0 |
| Stillwater Creek Skilled Nursing And Therapy | 21.1 mi | ★★★★★ | 0 | 0 |
| Westhaven Nursing Home | 22.1 mi | ★★★★★ | 6 | 0 |
| Linwood Village Nursing & Retirement Apts | 24.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Southern Oaks Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.