Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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.
A resident with hypothyroidism, stroke, diabetes, and kidney failure did not receive her prescribed levothyroxine after admission. Her prior records and discharge paperwork listed levothyroxine 112 mcg daily, but the current EHR and MAR did not include the medication, and staff said they were unaware of the diagnosis or order. A family member reported the resident said she had not been given her thyroid medication, and a hospital RN later noted her TSH was very high and she needed twice the normal dose of levothyroxine.
A resident with psychiatric diagnoses and intact cognition had a nutritional problem identified in her care plan and was ordered monthly weights, but staff did not recognize a significant weight loss from about 151 lb to 127 lb. Meal records showed repeated partial intake and refusals, and observations found her pushing trays aside, saving grilled cheese sandwiches for later, or not eating at all. Interviews with the ADON, CNA, MA, RN, Dietary Manager, and Dietitian showed staff were generally unaware of the weight loss or inconsistent intake.
Two CNAs failed to follow the facility’s infection control policies during incontinence care for two residents. One resident, who had a feeding tube and was on enhanced barrier precautions, received care from CNAs who entered the room without gowns, donned gloves without prior hand hygiene, performed perineal care including handling stool and soiled briefs, and then applied a clean brief without changing gloves or performing hand hygiene, leaving the room without washing their hands. Immediately afterward, the same CNAs provided incontinence care to another resident with bladder incontinence, again donning gloves without hand hygiene, cleansing the perineal area and removing a heavily urine-soaked brief, then applying a clean brief without changing gloves or washing hands, and exiting without hand hygiene. In interviews, both CNAs acknowledged knowledge of hand hygiene and PPE expectations but cited forgetting or lack of clarity, and the ADON confirmed that the CNAs’ actions did not meet facility policy or her expectations, noting that one CNA had not yet received infection control training.
Surveyors found that staff did not maintain accessible call lights for four residents with conditions including contractures, hemiplegia, epilepsy, polyneuropathy, mobility limitations, and varying levels of cognitive impairment. Each resident’s care plan required that the call light be kept within reach due to dependence on staff for ADLs and fall risk, yet observations showed call lights on the floor, coiled on the bed frame out of reach, or hung on a repositioning bar that was difficult for a resident to access. Residents reported being unable to find or easily reach their call lights, while staff interviews confirmed that call lights are essential for residents to request assistance and that staff are responsible for ensuring accessibility, contrary to the facility’s written policy requiring accessible call systems at bedside.
A resident with dementia, hemiplegia, hemiparesis, and moderate cognitive impairment, who was incontinent and care planned to prevent skin breakdown, was found in bed with a tube of barrier cream left on the bedside table, visible and accessible to the resident and others. The resident stated staff used the cream during incontinence care and sometimes left it on the side table. An LVN acknowledged the cream should have been stored in the treatment cart and not within the resident’s reach. The ADON and Administrator both stated that medications should not be stored in residents’ rooms and that staff were expected to scan rooms for medications, consistent with the facility’s policy requiring all medications and biologicals to be stored in locked compartments.
A resident with prostate CA, a documented cognitive communication deficit, and partial visual impairment was admitted for rehab with a family member designated as responsible party, who signed all admission documents. Despite this, the administrator later called the resident alone into the office, presented a NOMNC, and had the resident sign it without notifying or involving the designated representative, even though the resident reported not understanding what he was signing and relying on family to handle his paperwork. The responsible party stated she was not informed of the discharge notice and only learned of it when the resident called saying he had signed papers and was being put out, while facility records and staff interviews showed the EHR listed a family responsible party and that prior instructions at admission were to have the family sign because the resident probably would not understand the documents.
A cognitively intact female resident with bladder incontinence and on antibiotic therapy for UTIs returned from the hospital overnight and received incontinence care once in the early morning but was then left in a wet brief for over seven hours. Despite activating her call light and being told by a nurse that a CNA would assist, no one returned to change her. The CNA assigned to her admitted not having checked on her since starting the shift, while the RN and DON stated staff were expected to round every 2–3 hours and provide incontinence care at least every 2 hours or when wet, consistent with the facility’s neglect policy.
Delayed Weekend Mail Delivery: The facility failed to ensure residents promptly received unopened mail on weekends. In a resident group interview, 6 of 6 residents stated they never receive mail on Saturday. The AD stated she delivers mail during the week but not on Saturday, and the BOM stated Saturday mail stays in the facility mailbox until Monday before being given to the AD for delivery. The facility mail policy stated mail is to be delivered within 24 hours, including Saturday deliveries.
Failure to provide written transfer/discharge notices and ombudsman notification: The facility sent three residents to the ER, including residents with intact cognition and significant medical conditions such as CHF, COPD, kidney failure, ESRD, and cirrhosis, but only made phone calls or left messages to family/RP. No written notice was documented for the resident, representative, or LTC ombudsman, and the notices did not include the required discharge reasons, appeal rights, or related information.
Failure to Provide Written Notice Before Room Changes: The facility did not ensure that residents received written notice, including the reason, before room changes were made. Records showed cognitively intact residents with multiple medical diagnoses were moved to other rooms, but documentation of written notice was absent, and one resident stated she was never given written notice when her room changed.
A CNA did not change soiled gloves or perform hand hygiene as required during incontinence care for a resident, instead continuing care and assisting with repositioning and dressing while wearing soiled gloves. The CNA only washed hands after completing all care, despite having received training on proper infection control procedures. Interviews confirmed that these actions were not in line with facility policy and expectations.
A resident with a colostomy and complex medical needs was found to have soiled linen left on the floor and bodily substances smeared on the wall and floor in their room. Staff interviews confirmed that proper protocols for handling contaminated linen were not followed, and there was a lack of timely communication to facility leadership about the incident. The facility's own policies for managing soiled laundry were not adhered to, resulting in a failure to maintain a clean and safe environment.
A resident with a colostomy and multiple complex diagnoses was readmitted from the hospital, but physician orders for ostomy care were not reactivated, and nursing staff did not consistently document the provision of colostomy care. This resulted in a lack of verification that required care was provided, contrary to facility policy and professional standards.
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in various areas, including the nurse's stations, kitchen, and dining room. Staff reported the issue but lacked a system for reporting sightings, and the new administrator acknowledged the problem, contacting a pest control company for assistance. Despite efforts, the pest issue persisted, with no pest control log or communication system in place.
The facility failed to maintain wheelchairs for eight residents, with issues such as cracked armrests and missing parts, posing safety risks. Additionally, the clean utility room was repeatedly left unlocked, allowing unauthorized access to medical supplies. Staff interviews revealed a lack of communication and procedures for reporting and repairing broken wheelchairs, with the new Administrator only recently addressing the issue.
The facility failed to secure medications and medical supplies, with an unlocked treatment cart on Hall 500 and an open clean utility room on Hall 200. LVN A admitted to leaving the cart unlocked due to confusion over responsibilities, while the utility room was accessed by an unidentified staff member and a resident. Interviews with the ADON and DON confirmed the need for locked storage to prevent harm.
The facility failed to follow professional standards for food safety, with unlabeled and improperly stored food items in the refrigerator and incorrect thawing practices observed in the kitchen. A block of cheese and dry cereal were found unsealed and without proper labeling, while a pan of chicken was improperly thawed in a sink without running water, contrary to the facility's policy.
A facility failed to maintain proper infection control practices. A CNA did not perform hand hygiene between glove changes during incontinence care, and an MA used personal scissors to cut lidocaine patches without cleaning them. Both actions were against facility policies, risking cross-contamination.
The facility failed to maintain a safe and sanitary environment, with issues such as a loose handrail and missing tiles in key areas. Staff interviews revealed inconsistent use of the maintenance logbook, with many issues reported verbally. High turnover in maintenance management may have contributed to these deficiencies.
A resident with multiple diagnoses did not receive recommended PASRR services, including habilitative therapy and a customized wheelchair, due to administrative delays and financial issues. The MDS coordinator and Director of Rehabilitation were aware of the recommendations, but the previous administrator did not approve the services. The new administration eventually ordered the equipment, but the delay affected the resident's mobility and comfort.
The facility failed to update care plans for three residents, leading to potential risks in care delivery. A resident's care plan was not revised to reflect the discontinuation of a condom catheter, another resident's plan did not include changes from a motorized to a manual wheelchair, and a third resident's plan lacked updates for a specialized wheelchair and habilitative services. Staff interviews revealed a lack of awareness and follow-up on these necessary updates.
Failure to Administer Prescribed Thyroid Medication
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when it did not administer her prescribed levothyroxine after admission. The resident was admitted with diagnoses including stroke with left-sided weakness and speech impairment, diabetes, kidney failure, and hypothyroidism. Her prior records, discharge instructions, physician history and physical, and medication administration record all reflected levothyroxine 112 mcg daily for hypothyroidism, and her prior care plan included interventions to give thyroid replacement therapy as ordered and monitor lab work. However, the current facility’s admission assessment did not mention hypothyroidism, and the current medication administration record did not list levothyroxine. During interviews, the Administrator stated there was no DON present and the ADON was not working that day. The NP stated he was unaware the resident had hypothyroidism and had no explanation for why she was not on thyroid medication, noting the facility’s EHR did not indicate levothyroxine use. An LVN stated he was unaware the resident was supposed to be on thyroid medication and did not review the prior facility’s history. A family member reported the resident later said she had not been given her thyroid medication, and a hospital RN stated the resident’s TSH was very high and she required twice the normal dose of levothyroxine. The facility’s medication administration policy stated medications shall be administered as prescribed by the attending physician.
Unmonitored Weight Loss and Inconsistent Meal Intake
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status based on the resident’s comprehensive assessment. The resident was a female with diagnoses including bipolar disorder, psychotic disorder, antisocial personality disorder, and homelessness. Her quarterly MDS showed a BIMS of 15, indicating intact cognition, and she was independent with eating. Her care plan identified a nutritional problem or potential nutritional problem, with interventions to serve the ordered diet and have the RN evaluate and make diet change recommendations. She was ordered monthly weights. Record review showed the resident’s weight remained around 147 to 151 pounds from admission through April, but a surveyor-observed weight on 05/06/26 was 127.4 pounds. Meal intake records from 04/11/26 to 05/07/26 showed multiple meals eaten at less than full intake, including 8 meals at 51% to 75%, 3 meals at 26% to 50%, and 6 refused meals. During observations, the resident often declined meals, pushed trays aside, or asked for grilled cheese sandwiches to be taken to her room to eat later. Staff interviews reflected that she ate sporadically, sometimes drank coffee instead of eating, and would become upset if encouraged to eat. Interviews with the ADON, CNA, MA, RN, Dietary Manager, and Dietitian showed staff generally did not notice or were not aware of the resident’s weight loss, and the Dietitian stated no one had told her the resident was not eating or had lost weight. The Dietitian also stated that if she had known the resident was losing weight, she would have recommended shakes as an intervention. The facility policy required monthly weights to be recorded no later than the 10th day of each month and for a licensed nurse to review weights the same day so questionable weights or significant changes could be followed up promptly.
Failure to Follow Hand Hygiene and PPE Requirements During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene and use of personal protective equipment (PPE) during incontinence care for two residents. Resident #1, a cognitively intact male with hypertension, aphasia, a feeding tube, and a wound, was on enhanced barrier precautions as reflected in his care plan. His care plan required proper signage, availability and use of PPE including gowns and gloves during high-contact care, and adherence to enhanced barrier precautions. Resident #2, a cognitively intact female with bilateral knee contractures and bladder incontinence, had a care plan directing staff to check for incontinence and to wash, rinse, and dry the perineal area and change clothing as needed after incontinence episodes. On the observed date, CNA B and CNA C entered Resident #1’s room to provide incontinence care. Both CNAs donned gloves without performing hand hygiene. Despite an enhanced barrier precaution sign and PPE available outside the room, neither CNA donned a gown before entering. CNA B cleansed Resident #1’s abdominal folds and perineal area using wet wipes and then turned the resident to clean his buttocks and thighs. The resident was noted to be wet and to have had a bowel movement; CNA B removed the soiled brief and discarded it. Without performing hand hygiene or changing gloves after handling the soiled brief and completing perineal care, CNA B applied a clean brief. Both CNAs then removed their gloves, took the trash, exited the room, and did not wash their hands. CNA B took the trash to the soiled closet and then proceeded directly to Resident #2’s room without hand hygiene. In Resident #2’s room, CNA B initially went to wash her hands but left before doing so to retrieve another bag of trash from Resident #1’s room, placed it in the soiled closet, and returned to Resident #2’s room. Without washing her hands, she donned gloves and prepared supplies; CNA C also donned gloves without hand hygiene. CNA B then cleansed Resident #2’s abdominal folds and perineal area, turned the resident to clean the buttocks and thighs, and removed a heavily urine-soaked brief. Without performing hand hygiene or changing gloves after handling the soiled brief, she applied a clean brief. Both CNAs positioned the resident, removed their gloves, took the trash, and left the room without washing their hands. In interviews, CNA C acknowledged she knew she was supposed to perform hand hygiene before resident contact, between care, and after glove removal, and to wear gowns for residents on enhanced barrier precautions, but stated she forgot. CNA B stated she knew she should perform hand hygiene before and after care and with each glove change but did not know she was supposed to change gloves between care, and admitted she did not wash her hands or change gloves between residents or between handling soiled and clean briefs, stating she had no reason and often forgot PPE when in a hurry. The ADON confirmed her expectation that staff perform hand hygiene before resident contact, between care, and with glove changes, and wear PPE for residents on enhanced barrier precautions, and acknowledged that CNA B had been employed for three weeks without receiving infection control training, despite facility policies requiring staff training and adherence to hand hygiene and PPE use.
Failure to Maintain Accessible Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to reasonable accommodation of needs and preferences by not maintaining accessible call lights for four residents. For one resident with contractures, hemiplegia, hemiparesis, moderate cognitive impairment, and dependence on staff for all ADLs, the comprehensive care plan required that the call light be within reach. During observation, this resident was in bed awake with the call light lying on the floor; she stated she used the call light to call staff, did not have it, could not find it, and that this was not the first time she could not find her call light. Another resident, with epilepsy, muscle wasting, lack of coordination, unsteadiness of feet, severe cognitive impairment, and needing assistance with transfers, bed mobility, toileting, showering, dressing, and hygiene, also had a care plan intervention to keep the call light within reach and was identified as at risk for falls. During observation, this resident was in bed awake with the call light coiled on the lowest bed frame, not within reach, and did not respond when asked where the call light was. A third resident, with difficulty walking, epilepsy, repeated falls, and a fracture, had a care plan intervention to keep the call light within reach following an actual fall. This resident was observed awake in bed with the call light on the floor and stated it had been on the floor since morning and staff had not returned it to the bed. A fourth resident, with obesity, polyneuropathy, intact cognition, and needing assistance with dressing, transfers, bed mobility, hygiene, and showering, was care planned as at risk for falls with an intervention to keep the call light within reach. This resident was observed awake in bed with the call light hanging on the repositioning bar; she reported staff always hung it there and that it was difficult for her to turn to get it, expressing a desire for it to be placed where it was easier to reach. Multiple staff, including LVNs and CNAs, acknowledged during interviews that call lights are important for residents to call staff when they need something or need assistance, and that staff are responsible for ensuring call lights are within residents’ reach. The facility’s written policy on call lights required that the call system be accessible to residents while in bed or other sleeping accommodations, which was not followed in these observed instances.
Improper Storage of Barrier Cream Left Accessible at Bedside
Penalty
Summary
The facility failed to store medications and biologicals in locked compartments and under proper controls, and failed to limit access to medications to authorized personnel, as required by State and Federal laws and facility policy. A resident with dementia, hemiplegia, hemiparesis, and moderate cognitive impairment (BIMS score of 09), who was incontinent of bowel and bladder and care planned to remain free from skin breakdown, was observed in bed with a tube of barrier cream left on the bedside table. The cream was visible and accessible to the resident and others in the room. The resident reported that staff used the cream when cleaning and changing her and that some staff sometimes left the tube on her side table. During subsequent observations and interviews, an LVN stated she did not know who left the barrier cream in the room and acknowledged that the tube should have been stored in the treatment cart or otherwise out of the resident’s reach. She indicated that residents might use the cream more than recommended or, if confused, might consume it. The ADON stated that medications should not be stored in residents’ rooms and that the tube of wound dressing cream should have been in the nurse’s cart and not within reach of any resident. The Administrator similarly stated that staff were expected to look around residents’ rooms for any medications, as residents could consume or use medications inappropriately if left at bedside. Review of the facility’s Medication Labeling and Storage policy reflected that all medications and biologicals were to be stored in locked compartments, which was not followed in this instance.
Failure to Involve Designated Representative in NOMNC and Discharge Preparation
Penalty
Summary
The deficiency involves the facility’s failure to provide and document sufficient preparation and orientation for a safe and orderly discharge, and failure to ensure that a resident’s designated representative was notified and involved when a Notice of Medicare Non-Coverage (NOMNC) was issued and signed. The resident was an older male admitted for rehabilitation with diagnoses including prostate cancer and a cognitive communication deficit. His admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that he was usually understood, usually understood others, and had adequate vision, though he required supervision or touch assistance with most ADLs. The care plan did not address any need for a representative’s involvement in decision-making, despite the electronic health record listing a family member as the resident’s responsible party and the admission agreement being signed by that family member as the designated representative. The Administrator met with the resident in his office, with the receptionist present, and presented the NOMNC, documenting that the last covered day and discharge date were explained and that the resident was asked about home health and discharge location. The NOMNC form showed that the Administrator notified the resident of the notice and that the resident signed it, with information that he could appeal if he disagreed. However, the Administrator did not notify or involve the resident’s designated responsible party at the time the NOMNC was issued or signed, even though the responsible party had signed all prior admission documents on the resident’s behalf. The Administrator later stated he considered the resident to be his own responsible party and believed the resident comprehended the NOMNC and appeal process, despite acknowledging he did not know why the resident was not listed as his own responsible party in the EHR or why he had not signed his own admission documents. The resident’s responsible party reported that she had been handling all of the resident’s business with the facility because he was heavily medicated, not coherent enough, and unable to read well, and that she had signed all prior documents. She stated she was not notified of the discharge notice, was not provided the NOMNC to sign, and only learned of it when the resident called and said he had to sign papers and was being “kicked out.” The resident stated he was partially blind in one eye from a cataract, was not comfortable reading, and allowed his family to handle his business. He reported that the Administrator stopped him on his way to the dining area, took him into the office, told him he had to sign some paperwork, and that he did not understand what he was signing but signed because he was told he had to. The receptionist confirmed she had been instructed by the former BOM at admission to have the family sign the admission agreement on the resident’s behalf because the resident probably would not understand what he was signing. The facility’s transfer and discharge policy required that transfer/discharge notices be provided to the resident and the resident’s representative in a language and manner they can understand, and CMS NOMNC instructions require that if an enrollee cannot comprehend the notice, it must be delivered to and signed by a representative. These requirements were not followed in this case.
Failure to Provide Timely Incontinence Care Resulting in Prolonged Wetness
Penalty
Summary
A cognitively intact female resident with a history of brain bleed, back pain, type 2 diabetes, bladder incontinence, and current antibiotic therapy for UTIs was admitted to the facility and returned from the hospital via ambulance late at night. Her care plan documented bladder incontinence with an intervention to check as required for incontinence. The resident reported she received incontinence care around 4–5 AM after returning around midnight, and by late morning she remained in a wet brief, stating she had not been changed again and that this was causing her distress. She also stated she was usually out of the facility in the mornings for therapy at another location and was present that morning only because she had just been discharged from the hospital. By early afternoon observation, the resident was still unchanged, indicating she had been left in the same brief for more than seven hours. The resident reported she had activated her call light about an hour earlier, a nurse had responded and said an aide would assist, but no one returned to provide incontinence care. The CNA assigned to the resident acknowledged she had not yet checked on the resident since coming on duty at 6 AM, stating she was busy and believed the resident had just returned from the hospital. The RN assigned to the resident stated CNAs were expected to make rounds every 2–3 hours and residents should be changed every 2 hours or when wet or soiled, and the DON confirmed the expectation that residents be checked every 2 hours and never left wet for more than 4 hours, noting that nurses could also provide incontinence care when CNAs were busy. The facility’s Abuse & Neglect policy defined neglect as deprivation of goods and services that would cause emotional distress.
Delayed Weekend Mail Delivery
Penalty
Summary
The facility failed to ensure residents had the right to send and promptly receive unopened mail and other letters, packages, and materials delivered to the facility for the resident, including items delivered by means other than postal service, for 6 of 6 confidential residents reviewed for weekend mail delivery. During a confidential resident group interview, all 6 residents stated they never receive mail on Saturday. In an interview, the AD stated the BOM brings her the mail during the week for distribution to residents, and she delivers it to residents' rooms or leaves it on their bedside tables if they are not in their rooms. The AD also stated she comes in on Saturday for activities but does not deliver mail. The BOM stated that during the week she separates facility mail from resident mail and gives resident mail to the AD, and that if mail is delivered on Saturday, it remains in the facility mailbox until Monday, when she retrieves it and gives it to the AD for delivery. Record review of the facility's mail policy, revised January 2011, stated mail will be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box, including Saturday deliveries.
Failure to Provide Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to notify residents and their representatives in writing of transfer or discharge, the reasons for the move, and the right to appeal, and failed to send a copy of the notice to the representative of the Office of the State Long-Term Care Ombudsman for 3 of 6 residents reviewed for discharge planning. The facility also did not provide the notice in a language and manner the residents and representatives could understand. Interviews with the LMSW and DON confirmed that when residents were sent to the hospital, staff called the family or representative, but no written notice was provided to the resident, resident representative, or local ombudsman. Resident #1 was a female admitted with diagnoses including acute CHF, emphysema, osteoarthritis, morbid obesity, type 2 diabetes, COPD, and chronic respiratory failure. Her MDS reflected a BIMS score of 15, indicating intact cognition. A progress note dated 09/01/2025 documented that she was sent to the ER and her family member was notified, but there was no evidence of a discharge notice sent to the resident, the resident's representative, or the LTC Ombudsman. Resident #2 was a female admitted with CHF, COPD, GERD, depression, asthma, morbid severe obesity with alveolar hypoventilation, and kidney failure, and her MDS reflected a BIMS score of 14. On 05/08/2025, she was sent to the ER for a critical hemoglobin level of 6.7 after the NP ordered transfer and the DON was notified; the RP could not be reached and a message was left. On 05/22/2025, the record also documented that the resident requested transfer to the ER per family and resident request. Resident #3 was a male admitted with end stage renal disease, epilepsy, atrial fibrillation, toxic liver disease with fibrosis and cirrhosis, CHF, and UTI, and his MDS reflected a BIMS score of 15. On 08/23/2025, the NP instructed that he be sent to the ER for further evaluation, the RP could not be reached, and a voicemail was left with the facility callback number. For Residents #2 and #3, there was no evidence of a discharge notice sent to the resident, the resident's representative, or the LTC Ombudsman.
Failure to Provide Written Notice Before Room Changes
Penalty
Summary
The facility failed to ensure that four of six residents received written notice, including the reason for the change, before their rooms were changed. Record review showed that Resident #1, a female with diagnoses including acute congestive heart failure, emphysema, osteoarthritis, morbid obesity, type 2 diabetes, COPD, and chronic respiratory failure, had a BIMS score of 15 indicating intact cognition. Her census record showed she was moved to another room, but progress notes did not contain written notification to the resident or representative explaining why the room change occurred. Social services documented speaking with the resident about her concerns and stating that she had been properly notified beforehand, but no written notice was found in the record. Resident #2, a female with diagnoses including CHF, COPD, GERD, depression, asthma, morbid severe obesity with alveolar hypoventilation, and kidney failure, had a BIMS score of 14 indicating she was cognitively intact. Her census record also showed a room move, and during interview she stated she had changed rooms but was never given written notice. Her progress notes contained no documentation or written notification to the resident or representative about the reason for the room change. Resident #3, a male with diagnoses including end stage renal disease, epilepsy, atrial fibrillation, toxic liver disease with fibrosis and cirrhosis, CHF, and UTI, had a BIMS score of 15 and was also moved to another room, with the census record reflecting the move.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA donned clean gloves and a gown after using hand gel in the hallway, then proceeded to provide incontinence care, including cleaning the resident's pubic, genital, and rectal areas. Throughout the process, the CNA did not change soiled gloves or perform hand hygiene between tasks, even after handling soiled materials and repositioning the resident. The CNA continued to assist with repositioning and dressing the resident while wearing soiled gloves, and only removed the gloves and gown at the end of care, washing hands afterward. Additionally, after removing dirty gloves, the CNA did not perform hand hygiene before donning new gloves and continued to assist with the resident's clothing and linens. Interviews with the CNA and the Director of Nursing (DON) confirmed that the facility's expectation and policy require hand hygiene before and after care, and glove changes after removing dirty gloves. The CNA acknowledged awareness of these procedures but did not follow them during the observed care, attributing the lapse to nervousness and distraction. Review of facility policies and recent in-service training indicated that the CNA had been trained on proper hand hygiene and infection control practices, including the requirement to wash hands after removing gloves and before direct contact with residents.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident, as evidenced by soiled linen being placed on the floor and the presence of a brown smeared substance on the wall above the linen. Additionally, dried brown substances and yellow liquid stains were observed on the floor next to the resident's bed. These conditions were documented through a photo and video provided by an anonymous employee, which showed the state of the room during the overnight shift. At the time of the surveyor's observation, the room was found to be clean, but the earlier evidence indicated a lapse in maintaining cleanliness and proper handling of soiled materials. The resident involved had a complex medical history, including colostomy status, hepatic encephalopathy, congestive heart failure, and end-stage renal disease. The resident was cognitively intact and had a care plan addressing behavioral issues related to the removal of his ostomy bag. Staff interviews confirmed that the resident had a pattern of removing his colostomy bag, which sometimes resulted in bodily fluids contaminating linens and potentially the environment. Despite this known behavior, staff did not consistently follow protocols for handling soiled linen, as soiled items were left on the floor rather than being immediately bagged and removed according to facility policy. Multiple staff members, including CNAs, LVNs, the ADON, and the DON, acknowledged that soiled linen should not be left on the floor and described the correct procedures for handling contaminated materials. However, there was a lack of clarity regarding who was responsible for the incident, and communication breakdowns were evident, as the DON and other leadership were not made aware of the situation until after the fact. The facility's policy required all soiled laundry to be handled as potentially contaminated, bagged at the location of use, and not sorted or rinsed in resident rooms, but these procedures were not followed in this instance.
Failure to Reactivate and Document Colostomy Care Orders After Resident Readmission
Penalty
Summary
The facility failed to provide colostomy care in accordance with professional standards and its own policies for a resident with a colostomy. Upon the resident's readmission from the hospital, physician orders for ostomy care, including changing the ostomy bag every three days, cleansing the area every shift, and emptying the bag every shift, were not reactivated. As a result, there were no active orders or documentation of ostomy care provided from the time of readmission until the orders were reinstated over three weeks later. During this period, nursing staff did not document the provision of colostomy or ileostomy care as required by facility policy. Interviews with nursing staff and administration confirmed that care may have been provided, but it was not consistently documented, and some staff admitted to not always recording the care they performed. The lack of documentation meant that there was no way to verify if the resident received the necessary ostomy care or if any issues were identified and addressed. The resident involved had a complex medical history, including colostomy status, hepatic encephalopathy, congestive heart failure, and end-stage renal disease. The resident was cognitively intact and did not refuse care. Facility records and staff interviews confirmed that the failure to reactivate orders and document care was contrary to both the facility's colostomy/ileostomy care policy and its charting and documentation policy, which require all treatments and services to be recorded in the medical record.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live flies and gnats in various areas, including the nurse's stations, kitchen, conference room, break room, and main dining room. Observations revealed flies and gnats in these areas, with flies seen crawling on leftover food and medication carts, and gnats around juice glasses. Staff interviews indicated that the pest issue was known, but there was no system in place for reporting sightings, and staff were unsure of how to address the problem. The facility's staff, including a medical assistant and a licensed vocational nurse, reported the persistent presence of flies and gnats since they began working at the facility. They noted that there was no pest control log or communication system in place, and they were not aware of any pest control personnel visiting the facility. The dietary manager confirmed that despite efforts to keep flies out, they remained a problem in the kitchen, and residents in a group meeting expressed that the issue had worsened over the past six months. The new administrator acknowledged the pest problem and stated that she had contacted a pest control company for immediate assistance. However, it was noted that there was no pest control book available for staff to report issues, and the facility was in the process of hiring a new maintenance person. The facility's policy, revised in July 2013, stated that an ongoing pest control program should be maintained, but this was not effectively implemented, leading to the deficiency.
Facility Fails to Maintain Wheelchairs and Secure Utility Room
Penalty
Summary
The facility failed to ensure that all assistive devices were maintained and free of hazards, specifically concerning the maintenance of wheelchairs for eight residents. Observations revealed that several wheelchairs had cracked armrests with exposed foam, missing armrests, and dried food substances on the wheels and back of the wheelchairs. These deficiencies were noted for residents with varying degrees of cognitive impairment and physical disabilities, including dementia, schizophrenia, muscle weakness, and other conditions requiring wheelchair mobility. Despite the residents' reliance on these wheelchairs for mobility, the facility did not maintain them in a safe and functional condition. Additionally, the facility failed to secure the clean utility room on Hall 200, which was repeatedly observed to be left unlocked and open. This room contained various medical supplies and equipment, including syringes, needles, catheters, and nutritional formulas, which were accessible to unauthorized individuals, including residents. Interviews with staff revealed a lack of awareness and responsibility regarding the security of the utility room, with some staff members unsure of who had access to the keys. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Registered Nurse (RN), Licensed Vocational Nurse (LVN), and the Assistant Maintenance person, highlighted a lack of communication and procedures for reporting and repairing broken wheelchairs. The new Administrator, who had only been in the position for two days, identified the issue and ordered parts for repairs. However, prior to this, there was no maintenance log or system in place to address the repair needs of wheelchairs, indicating a systemic failure in maintaining essential equipment for resident safety.
Medication and Supply Security Lapses
Penalty
Summary
The facility failed to ensure the security of medications and medical supplies, as observed during a survey. On Hall 500, a treatment cart was left unlocked and unattended in the hallway, outside of a resident's room. LVN A admitted to forgetting to lock the cart after retrieving supplies, acknowledging that the cart should always be locked to prevent unauthorized access to medications. This oversight was attributed to confusion over the responsibility of charge nurses completing their own treatments on the hallways. Additionally, the clean utility room on Hall 200 was repeatedly found unlocked and open throughout the morning, despite a sign instructing that it should be kept closed and locked when not in use. The room contained various medical supplies, including suction equipment, nutritional formulas, catheters, syringes, and medications. An unidentified staff member and a resident were observed accessing the room, with the staff member noting that the door should be locked and expressing uncertainty about who had keys to the room. Interviews with the ADON and DON confirmed that both the treatment carts and the clean utility room should be locked when not in use to prevent potential harm to residents. The DON mentioned plans for additional in-services to remind staff of the importance of securing medications. The Administrator also emphasized that it is basic nursing practice to keep treatment carts locked when not in use, and that staff using the carts are responsible for ensuring they are secure.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. During an inspection of the walk-in refrigerator, it was noted that a partially used block of cheese was stored in an unsealed bag without any labeling to indicate its contents, the date it was placed in the bag, or its use-by date. Additionally, two storage bags containing dry cereal were found unsealed, with only a date opened marked on them, but no expiration date. These lapses in labeling and sealing food items are contrary to the facility's policy, which requires all foods to be stored wrapped or in covered containers, labeled, and dated to prevent cross-contamination. Further observations revealed improper thawing practices. A pan of chicken was found in a large sink, immersed in water, but the water was not running, which is against the facility's policy that requires food to be thawed under running water to prevent contamination. The Dietary Manager (DM) acknowledged the error and stated that staff are expected to thaw items in the refrigerator. The cook admitted to turning off the water out of habit and acknowledged the importance of proper food handling to prevent illness. The facility's Food Storage Policy, revised in February 2023, outlines specific procedures for thawing frozen items, which were not followed in this instance.
Infection Control Deficiencies in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA C and MA D. CNA C was observed providing incontinence care to a resident without performing proper hand hygiene between glove changes. During the care, CNA C changed gloves multiple times without washing hands or using hand sanitizer, which is against the facility's policy. This lapse in protocol occurred despite CNA C acknowledging the importance of hand hygiene to prevent the spread of infection. Additionally, MA D was observed using personal scissors to cut lidocaine patches for a resident without cleaning the scissors before or after use. This action was contrary to the facility's policy on cleaning and disinfecting resident-care items. MA D admitted to not considering the need to clean the scissors, which could potentially lead to cross-contamination. The Director of Nursing confirmed the expectation for staff to perform hand hygiene and clean equipment to prevent cross-contamination.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in two of its halls, the nursing station area, the Central Supply, and the dining area. Observations revealed that a handrail near the Central Supply Room in the 500 hall was separated from the wall, creating a gap. Additionally, tiles near the central Nursing Station and in the dining area were loose or missing, exposing the concrete floor beneath and allowing a buildup of a black substance. These issues were not recorded in the facility's maintenance log, indicating a lack of formal reporting and tracking of maintenance needs. Interviews with staff, including CNAs and the Maintenance Tech, revealed that while there was a maintenance logbook intended for reporting issues, it was not consistently used. Staff often reported issues verbally, and the Maintenance Tech was unaware of some of the problems, such as the loose handrail. The facility had experienced high turnover in maintenance management, with five managers in six months, which may have contributed to the lack of attention to these environmental deficiencies. The ADM, who was new to the facility, was also unaware of the specific issues but expected the maintenance logbook to be used for reporting.
Failure to Implement PASRR Recommendations for Resident
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR evaluation report into the care planning and transition of care for a resident with cerebral palsy, intellectual disability, bipolar disorder, and scoliosis. The resident was supposed to receive habilitative services, including physical therapy, occupational therapy, and a customized wheelchair, as recommended during an IDT meeting. However, these services were not provided within the required timeframe, which could potentially impact the resident's physical, mental, and psychosocial well-being. Interviews revealed that the MDS coordinator was aware of the recommendations and had completed the necessary paperwork, but the resident had not received the habilitative therapy or the customized wheelchair. The Director of Rehabilitation confirmed that the previous administrator had refused to order the wheelchair or contact the DME company, citing financial constraints due to the company's bankruptcy. The new administration eventually ordered the equipment, but the delay had already affected the resident's mobility and comfort. The resident expressed dissatisfaction with the current wheelchair, which was not customized and did not fit properly, leading to reduced mobility. Staff interviews corroborated that the resident was waiting for the specialized wheelchair and had not been receiving the recommended therapies. The previous administrator admitted to not approving the services due to financial issues, while the new administrator acknowledged the oversight and took steps to rectify the situation.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plans for three residents, which could place them at risk for not receiving appropriate care. Resident #52's care plan was not updated to reflect the discontinuation of a condom catheter, despite physician orders indicating it was no longer medically necessary. This oversight occurred even though the care plan had been edited after the catheter was discontinued. Resident #53's care plan was not revised to include goals and interventions for the transition from a motorized wheelchair to a manual wheelchair. This change was recommended for safety reasons due to the resident's poor trunk control, as noted in occupational therapy assessments. Despite these recommendations, the care plan did not reflect the necessary updates to address the resident's current mobility needs. Similarly, Resident #65's care plan lacked updates to reflect the need for a specialized wheelchair and habilitative services, as recommended during a PASRR meeting. The care plan did not include goals and interventions for this change, which was necessary due to the resident's condition. Interviews with facility staff revealed a lack of awareness and follow-up on these care plan updates, contributing to the deficiencies identified.
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 1,122 citations issued within 25 miles in the last 12 months — including the 49 immediate-jeopardy cases — 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 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 | — | 0 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Southern Oaks Therapy And Living 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.