Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Therapy And Living Center during CMS and state inspections, most recent first.
Instances of inadequate supervision and improper fall response protocols were identified. A resident with severe cognitive impairment and a history of falls was able to leave the facility unsupervised multiple times, eventually being found outside the facility. Another resident with cognitive impairment and mobility issues was found on the floor in a common area, and a CNA moved the resident without a nurse's assessment, contrary to established protocols.
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, with issues such as missing paint, sticky floors, strong odors, cracked ice chest straps, and non-functional public bathrooms. Maintenance and housekeeping staff acknowledged the problems, but they were not adequately addressed. The administrator was unaware of the extent of the facility's condition.
The facility's kitchen failed to meet food safety standards, with spoiled food, pest issues, and significant equipment and structural deficiencies. Spoiled salad was found in the refrigerator, and live flies and gnats were observed in the dishwashing and food preparation areas. Key kitchen equipment was inoperable, and structural damage hindered proper cleaning. Staff confirmed these issues, citing a lack of funds for repairs.
A CNA failed to perform proper hand hygiene while serving meals, despite having received training. This was observed with multiple residents who had significant medical conditions, increasing their risk of infection. The DON confirmed the importance of hand hygiene and the CNA's awareness of the protocol.
The facility failed to maintain an effective pest control program, resulting in the presence of houseflies and gnats in the kitchen and a common area near the nurse's station. Observations revealed live insects in the dishwashing and food preparation areas, as well as around the main nursing station. The Operations Manager confirmed a gap in pest control services and was unaware of a missing screen in the kitchen window, and the facility could not provide pest control policies upon request.
The facility failed to secure medications and properly dispose of syringes, leaving Resident #13's Santyl ointment and Resident #14's Triamcinolone cream unsecured in their rooms, and 17 uncapped insulin syringes in Resident #15's room without a bio box. The DON was unaware of these lapses, and the facility's medication storage policy was not available for review.
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of colostomy bag changes. The resident required assistance with his colostomy bag, which was to be changed every 72 hours. However, the facility did not document the colostomy bag change on multiple occasions, including a specific instance where the DON and night nurse failed to document the change, leading to potential risks of double treatments and misconceptions among the interdisciplinary team about the care provided.
The facility experienced significant staffing shortages, failing to provide sufficient nursing staff on multiple occasions, which impacted resident care. A resident with severe medical conditions did not receive timely incontinent care, highlighting the facility's inability to meet resident needs due to inadequate staffing. Staff interviews revealed reliance on PRN nurses and refusal to use agency staff, exacerbating the issue.
The facility failed to maintain required RN coverage for at least 8 hours a day, 7 days a week, over 24 out of 39 days, and lacked a full-time DON for a period. This placed residents at risk of missed nursing assessments and care. RN E, RN F, and RN L worked insufficient hours on multiple days, and the RCNO acted as interim DON without being present in February.
A resident in a LTC facility did not receive 20 out of 40 doses of Pregabalin due to a failure in medication reconciliation and ordering. The facility continued administering medications that were supposed to be discontinued and did not adjust dosages as per hospital discharge orders. The consultant pharmacist failed to conduct monthly medication regimen reviews and did not implement a compliant system for handling controlled medications.
The facility failed to ensure dietary staff wore hair restraints, properly sealed, labeled, and dated foods in the walk-in cooler, and maintained the cooler's temperature below 41°F. Additionally, food temperatures were not monitored and recorded as required.
Deficiencies in Resident Supervision and Fall Response Protocols
Penalty
Summary
The report highlights several instances where the facility failed to ensure a safe environment for residents, leading to significant deficiencies. In the case of Resident #1, who had severe cognitive impairment and a history of falling, the staff allowed him to leave the facility unsupervised multiple times. This lack of supervision resulted in Resident #1 leaving the facility unnoticed, exposing him to potential harm as he was found sitting in front of his demolished house across the street. Additionally, Resident #2, who had severe cognitive impairment and mobility issues, was found on the floor in a common area without proper assistance. The staff failed to follow protocols for responding to falls, as evidenced by the observation where a CNA moved Resident #2 without a nurse's assessment, potentially risking further injury to the resident.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents across multiple halls and bathrooms. Observations revealed numerous issues including missing paint and plaster, sticky floors, dark red stains, and continuously running water in resident bathrooms. Additionally, there were strong odors of urine, cracked and wet ice chest straps, and murky water under the ice chest. Hallways were observed with dark stains, discolored dried stains, and falling baseboards. Public bathrooms were taped off and unusable due to plumbing issues. The ceiling above fire doors had large cracks, and several light fixtures were not working in the nurse's station and medication room. A hole the size of a golf ball was noted in one of the walls in a resident's room. Interviews with housekeeping and maintenance staff revealed that these issues were known but had not been addressed adequately. The administrator acknowledged the maintenance problems but was unaware of the extent of the facility's condition. The facility's failure to maintain a clean and safe environment was evident in the observations and interviews conducted. Housekeeping staff indicated they had sufficient cleaning products and followed cleaning protocols, yet the issues persisted. The Special Operations Director and the Administrator both acknowledged that the maintenance problems were their responsibility, but there was a clear lack of action to address these deficiencies. The administrator admitted that the condition of the facility could negatively impact how residents felt about living there. The facility's policy on maintenance services could not be reviewed as the administrator did not have access to the policies online, and no policies were provided by the time of the survey exit.
Food Safety and Equipment Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food safety in its only kitchen. Observations revealed that two bags of prepared salad in the walk-in refrigerator were spoiled and foul-smelling, with one bag torn and past its expiration date. Additionally, live flies and gnats were observed in the dishwashing and food preparation areas, with an open window lacking a screen contributing to the pest issue. The kitchen manager confirmed the spoilage and the presence of pests, acknowledging the risk of foodborne illnesses to residents. Further observations and interviews highlighted significant equipment and structural issues in the kitchen. The plate warmer, deep fryer, and most of the ovens and burners were inoperable, and the garbage disposal was not functioning. The wall behind the steam table area was missing tiles and baseboards, exposing grime-covered drywall and floor areas that could not be properly cleaned. Both the kitchen manager and cook confirmed the long-standing nature of these issues, while the operations manager and administrator cited a lack of available funds as the reason for the unaddressed repairs.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of one CNA who did not perform proper hand hygiene after direct contact with residents while serving meals. This failure was observed during meal service, where the CNA adjusted her clothing, touched residents and their belongings, and moved between rooms without washing her hands or using hand sanitizer. Despite having received training on hand hygiene, the CNA admitted to not following the protocol due to nervousness and the pressure to serve meals quickly. The deficiency was observed with multiple residents, all of whom had significant medical conditions and required assistance with activities of daily living. For instance, Resident #6 had dementia, Parkinson's disease, and diabetes, while Resident #7 had severe cognitive impairment and multiple health issues including atrial fibrillation and hypertension. Other residents involved had conditions such as stroke, heart failure, and chronic kidney disease, making them particularly vulnerable to infections. Interviews with the CNA and the Director of Nursing (DON) confirmed that the CNA was aware of the hand hygiene requirements but failed to adhere to them. The DON emphasized the importance of hand hygiene in preventing the spread of germs and stated that all staff were trained to use hand sanitizer between serving each tray. However, the facility's infection control policy could not be reviewed as the Administrator did not have access to it, and the request for policies was still pending at the time of the survey exit.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of houseflies and gnats in both the kitchen and a common area near the nurse's station. Observations on multiple occasions revealed live houseflies and gnats in the dishwashing and food preparation areas of the kitchen, as well as around the main nursing station. A window in the dishwashing area was found to be open and not equipped with a screen, allowing insects to enter the facility. These observations were made on 04/29/24 and 04/30/24, with flies and gnats seen landing on residents and commonly touched surfaces, posing a risk of infection and discomfort to the residents. In an interview and record review, the Operations Manager (OPS) confirmed that the facility had a gap in pest control services from 11/1/23 to 02/01/24, during which there was no active pest control contract or treatments. The OPS was unaware of the missing screen in the kitchen window and stated that the facility did not have significant pest issues during the gap period. However, the facility was unable to provide pest control policies upon request, indicating a lack of proper documentation and oversight in maintaining an effective pest control program.
Failure to Secure Medications and Properly Dispose of Syringes
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and only accessible to authorized personnel. Specifically, Resident #13's Santyl ointment was found unsecured beside the refrigerator in his room. Resident #13, who was alert and oriented, confirmed that the medication was left there by the nurses until it was used up. Similarly, Resident #14's Triamcinolone cream was found on the bedside table, and Resident #14 indicated that the medication was left there by the nurses for application. Both residents were capable of making decisions and required assistance with daily living activities, but the medications were not stored in locked compartments as required by professional principles. Additionally, Resident #15's room contained 17 uncapped insulin syringes in a plastic shelf, with no bio box present for proper disposal. Resident #15, who was also alert and oriented, was unaware of the proper disposal of used syringes, indicating a lapse in protocol by the nursing staff. Interviews with the treatment nurse and LVN F revealed that medications and treatments should be locked in the treatment cart and not left in residents' rooms unless there was a specific order to do so. The DON, who was new to the position, was unaware of these lapses and acknowledged the potential negative effects of leaving medications unsecured. The facility's policy on medication storage was not available for review as the Administrator did not have access to the policies online, and no policies were provided by the time of the exit interview.
Failure to Document Colostomy Bag Changes
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of colostomy bag changes. The resident, a male with a diagnosis of acute respiratory failure with hypoxia and schizoaffective disorder, required assistance with his colostomy bag, which was to be changed every 72 hours. However, the facility did not document the colostomy bag change on multiple occasions, including a specific instance on 04/08/24, leading to potential risks of double treatments and misconceptions among the interdisciplinary team about the care provided. On 04/08/24, the Director of Nursing (DON) was informed by a CNA that the resident needed his colostomy bag changed. The DON was unable to find the necessary supplies in the medication room or central supply and instructed the CNA to keep the resident clean to prevent cross-contamination. The DON communicated to the night nurse to change the colostomy bag as the first task, but the documentation of this change was not recorded. Interviews with the DON and other staff revealed that the night nurse did change the bag but failed to document it, citing various excuses. The facility's policy on charting and documentation compliance requires all services provided to residents to be documented in their clinical records. This includes the date and time of the procedure, the name and title of the individual providing care, and other relevant details. The failure to document the colostomy bag changes as per the policy led to incomplete and inaccurate clinical records for the resident, highlighting issues in the facility's documentation practices.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff on a 24-hour basis to meet the needs of residents, as evidenced by staffing shortages on multiple days between February and March 2024. The facility's staffing model, which was supposed to flex with resident needs, did not adequately address the staffing shortages, leading to situations where only one nurse was available to care for a large number of residents. This was compounded by issues such as staff not showing up for shifts, particularly after a payroll issue on February 23, 2024, when staff walked out or did not return to work. Resident #2, a [AGE] year-old female with a history of severe medical conditions including hemiplegia, aphasia, and chronic kidney disease, was directly affected by the staffing deficiencies. On March 4, 2024, it was observed that Resident #2 had not received timely incontinent care, resulting in her being found soaked in urine. Her family member, who regularly assisted with her care, expressed concerns about the lack of staff and the impact on Resident #2's care, including missed blood sugar checks and medication administration. Interviews with staff revealed that the facility often operated with minimal staff, leading to situations where nurses were unable to follow up on resident needs adequately. Staff reported working extended hours and being the sole nurse on duty, which compromised their ability to provide thorough care. The facility's reliance on PRN nurses and refusal to use agency staff further exacerbated the staffing issues, leaving residents at risk of not receiving necessary care and services.
Deficiency in RN Coverage and DON Presence
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week, over a period of 24 out of 39 days. Specific dates were identified where RN coverage was insufficient, with some days lacking any RN presence within a 24-hour period. This deficiency was observed through a review of clock in/out reports and interviews with staff members. RN E, who worked PRN on weekends, was on-site for less than 8 hours on several occasions, and RN F and RN L also worked less than the required hours on multiple days. Additionally, the facility did not have a full-time Director of Nursing (DON) from mid-February to early March, with the RCNO acting as an interim DON without being present in the facility during February. The absence of adequate RN coverage and a full-time DON placed residents at risk of missed nursing assessments, interventions, care, and treatments. Interviews with staff revealed that RN E performed various tasks to support the nursing team, such as reviewing charts and performing wound care, but her hours were insufficient to meet regulatory requirements. The NFA acknowledged the importance of RN coverage and indicated that a new DON was scheduled to start soon, which was expected to improve staffing issues. However, during the period reviewed, the facility did not adhere to its staffing policy, which mandates RN presence for a minimum of eight hours per day.
Medication Management Deficiency in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, leading to significant medication errors. Upon readmission from an acute hospital stay, the facility did not reconcile the resident's medications according to the hospital discharge orders. As a result, the resident did not receive 20 out of 40 doses of Pregabalin, a medication prescribed for nerve pain, because it was not ordered from the pharmacy. Additionally, the staff failed to retrieve the medication from the emergency kit, where it was available, on the days it was missed. The facility also continued to administer medications that were supposed to be discontinued according to the hospital discharge orders. These included Alprazolam, Cyclobenzaprine, Gabapentin, and Hydrocodone-Acetaminophen. Furthermore, the facility did not adjust the dosage of Metformin as instructed, and Aspirin was not administered as per the discharge orders. These discrepancies indicate a failure in the medication reconciliation process and a lack of communication between the facility staff and the pharmacy. The consultant pharmacist did not conduct a complete medication regimen review (MRR) monthly, as required, which contributed to the oversight in medication management. The pharmacist also failed to implement a system for handling and disposing of controlled medications in compliance with federal and state laws. This lack of oversight and failure to adhere to protocols placed the resident at risk of not receiving necessary medications, potentially exacerbating their medical conditions.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure dietary staff wore hair restraints while preparing food, as observed when a dietary aide was seen preparing meat and opening a can of applesauce without a hair restraint. Additionally, the facility did not properly seal, label, and date foods stored in the walk-in cooler. Specific observations included uncovered and undated plates of salad, an undated container with a reddish liquid, and opened packages of hard-boiled eggs that were not labeled or dated. The internal temperature of the walk-in cooler was also found to be 50°F, which is above the required temperature of below 41°F. Furthermore, the facility did not monitor and record the walk-in cooler temperatures since January 27, 2024, as per their policy, and failed to take and record prepared food temperatures prior to meal distribution on January 28 and January 29, 2024. During an interview, Cook C admitted that the lunch meal temperatures had not been taken before serving and that the cooler felt warmer than usual. Cook C also acknowledged that the temperature logs for the walk-in cooler and freezer were not maintained, and that dietary staff were recently trained on proper food storage but failed to comply. The Dietary Manager (DM) was unaware of the issues observed and stated that all dietary staff were expected to follow state rules and the dietitian's guidelines, including wearing hair restraints, monitoring and recording cooler temperatures, and ensuring proper food storage. Further interviews revealed that the dietary aide (DA B) was trained to wear a hairnet and perform hand hygiene but forgot to put on a hairnet in a hurry. DA B also mentioned that the undated container with the reddish liquid was a Kool-Aid and tea mixture made for lunch, and that another dietary aide was asked to date it. The Administrator (ADMIN) confirmed awareness of the issues and emphasized the importance of compliance with state and federal rules to prevent foodborne illnesses. The facility's policies on food receiving, storage, and refrigerator/freezer maintenance were reviewed, highlighting the requirements for proper food handling and temperature monitoring.
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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.
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Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southern Oaks Therapy And Living Center | 0 mi | ★★★★★ | 24 | 0 |
| The Villages Of Dallas | 1.8 mi | ★★★★★ | 11 | 0 |
| Fair Park Health & Rehabilitation Center | 3.6 mi | ★★★★★ | 7 | 0 |
| Ventana By Buckner | 4.6 mi | ★★★★★ | 3 | 0 |
| Simpson Place | 4.9 mi | ★★★★★ | 16 | 0 |
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