Southern Oaks Therapy and Living Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 3 residents (Resident #1) reviewed for resident rights. -The facility failed to accommodate Resident #1's needs by not ensuring that his call light was within reach for him to call for assistance when needed. -The facility failed to accommodate Resident #1's needs by not providing a functional and properly fitted wheelchair to maintain the resident's independence. These failures could place residents at risk of a decline in their dignity and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the bed rails, mattress, and bed frame were compatible for 2 of 6 residents (Resident #2 and Resident #3) reviewed for physical environment. -The facility failed to provide Resident #2 and Resident #3 with a mattress that was functional, comfortable, and appropriate to their needs. This failure could place residents at risk of not having appropriate furniture to accommodate special needs, which could affect their health, comfort, and safety.

Inspectors wroteBased observation, interview, and record review the facility failed to notify the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status or need to alter treatment for 1 resident (Resident #1) of 6 residents reviewed for resident rights. The facility failed to notify Resident #1's delegated representative of a change in treatment on 05/13/26 when the physician ordered an antipsychotic medication, Risperidone 1 mg, to be administered twice daily. This failure could place residents at risk of not being able to exercise their rights regarding care, which could lead to harm or decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #1) reviewed for medication errors. The facility failed to administer Resident #1's thyroid medication since she was admitted on [DATE]. This failure could place residents at risk of their medical conditions worsening from lack of treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, based on a resident's comprehensive assessment, residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #1) reviewed for nutrition. The facility failed to monitor Resident #1's weight and meal intake which resulted in the resident's weight loss not being identified. This failure placed residents at risk for loss of weight and inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #1 and #2) reviewed for infection control practices.1. CNA B and CNA C failed to perform hand hygiene before contact, between care, and change of gloves while providing incontinence care to Resident #1 and Resident #2.2. CNA B and CNA C failed to put on PPE while providing incontinence care to Resident#1, who was on enhanced barrier precautions due to having a feeding tube. These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #1, #2, #3, and #4) of fifteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2, #3, and #4's rooms was in a position that was accessible to the residents on 02/015/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Residents #1) of ten residents reviewed for medication storage. The facility failed to ensure that Resident #1's barrier cream was stored properly and not left on the resident's side table visible and accessible to the resident and other residents on 02/15/2026. These failures could place the residents at risk of misuse of medications and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 3 residents (Resident #1) reviewed for discharge. The facility failed to ensure that Resident #1's responsible party was notified of the resident's discharge, following (or at the time of) the issuance of a NOMNC notifying the resident of the end of his Medicare-covered services, before Resident #1, who did not fully understand the contents, signed the notice. This failure could place residents at risk of not having access to available advocacy services, discharge options, and appeal processes, which could result in an unsafe discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide service for incontinent care for 1 of 5 residents (Resident #2) reviewed for incontinent care, in that: The facility failed to provide incontinent care to Resident #2, which resulted in Resident #2 being left unchanged for approximately 7 hours. This failure could result in skin sores, infection and could affect resident's dignity.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure four out of six Residents the right to receive written notice, including the reason for the change, before the resident's room in the facility is changed. The facility did not provide evidence that four out of six Residents was given a written notice of a room change before the resident was moved. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment. Record review of Resident #1 revealed resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute congestive heart failure, emphysema, osteoarthritis, morbid (severe) obesity, type 2 diabetes, chronic obstructive pulmonary disease, and chronic respiratory failure. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service for 6 of 6 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents promptly received their mail on the weekend. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life. During a confidential resident group interview 6 of 6 residents stated that they never receive mail on Saturday. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the resident and resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for discharge planning. - The facility failed to notify the resident/ residents representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand. - The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #1, #2, and #3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (CNA A) of two staff observed for infection control. CNA A failed to change their soiled gloves and wash hands during incontinent care to Resident #1. This failure could place residents at risk for spread of infection through cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 5 (Resident #1) residents reviewed for resident rights. 1. The facility failed to ensure on 04/17/25, during the overnight shift, that Resident #1's room was without soiled linen placed on the floor and a brown smeared substance was on the wall directly above the soiled linen. 2. The facility failed to ensure on 04/17/25, during the overnight shift, that Resident #1's floor next to his bed was without dried up brown substances and yellow liquid stains. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept and clean environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice for 1 of 5 (Resident #1) residents reviewed for ostomies (surgical opening from an area inside the body to the outside). 1. The facility failed to follow their Colostomy-Ileostomy policy as the nursing staff did not document each time colostomy/ileostomy care was provided for Resident #1. 2. The facility failed to ensure Resident #1's physician's order for changing of his ostomy bag (every 3 days), order for cleansing the area (every shift), or the order for emptying the bag (every shift) was reactivated on 04/01/25 when Resident #1 readmitted to the facility from the hospital. These findings placed resident at risk of complications related to a colostomy. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for five (Halls 100, 200, 300, 400, 500 nurse's station, kitchen conference room break room, and the main dining room), of five halls reviewed for pest control program. The facility had live flies and gnats in areas of the facility including the nurse's station, Halls 100, 200, 300, 400, 500, conference room, break room, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for eight (Residents #2, #4, #5, #8, #11, #54, #55, and #158) of twelve residents reviewed for essential equipment and one of one clean utility room reviewed for hazards. The facility failed to ensure treatment supplies in the clean utility room on Hall 200 was secured or attended by authorized staff when unlocked. The facility failed to properly maintain wheelchairs for Residents #2, #4, #5, #8, #11, #54, #55, and #158. These failures could place residents at risk for equipment that was in unsafe operating condition, which could cause injury and/or resident access to harmful supplies leading to a risk for injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for one (Hall 500 ) of one treatment cart reviewed for prescribed treatment medication storage and one (Hall 200 clean utility room) of one clean utility room reviewed. The facility failed to ensure treatment supplies were secured or attended by authorized staff when LVN A's treatment cart for Hall 500 was left unlocked. The facility failed to ensure medical supplies were secured or attended by authorized staff when the clean utility room was left unlocked on Hall 200. This failure could result in resident access and ingestion of prescribed treatment medications and obtaining harmful supplies leading to a risk for harm and possible drug diversion.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety. 1 The facility failed to ensure food items in the refrigerator, were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date, and/or the consume by or expiration by dates (if opened, 72 hours per the facility's policy or the manufacturer's expiration date) stored in accordance with the professional standards for food service. 2. The facility failed to ensure food items were thawed by, completely submerging the item under cold water (at a temperature of 70 degrees F or below) that was running fast enough to agitate and float off loose ice particles. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (CNA C) of two staff observed for infection control. CNA C failed to wash hands or use hand sanitizer after each change of soiled gloves and wash hands during incontinent care to Resident #52. MA D failed to cleanse scissors before and after usage when administrating lidocaine patches to Resident #153. This failure could place residents at risk for spread of infection through cross-contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 (Halls 100 and 500) of 4 halls, the nursing station area, the Central Supply, and the dining area reviewed for environment. The facility failed to ensure that surfaces were clean and devoid of marring or defect, that handrails were in good repair, and that the flooring was in good repair near rooms residents #55, #56, #6, #10 the nursing station area, dining area, and the 500 hall. These failures could affect residents and the staff by placing them at risk for diminished quality of life due to lack of a well-kempt environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for one (Resident # 65) of one resident reviewed for PASRR services. The facility did not provide Habilitative Services (Physical Therapy, and Occupational Therapy) and Durable Medical Equipment(DME)/ Customized Wheelchair for Resident #65 per PASRR recommendations made at the Interdisciplinary Team (IDT) meeting held on 3/26/2024 within 20 days. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's status, for 3 of 4 residents (Resident #52, #53, and Resident #65) reviewed for care plans. The facility did not update Resident #52's care plan to reflect goals and interventions for the discontinuation of the Condom Catheter. The facility did not update Resident #53's care plan to reflect goals and interventions for the change from a motorized wheelchair to a manual wheelchair. The facility did not update Resident #65's care plan to reflect goals and interventions for the PASRR meeting and the ordering of a specialized wheelchair and habilitative services. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs.