Southern Oaks Nursing & Rehabilitation Center

Based on record review and interviews the facility failed to implement the care plan for 1 (#28) of 22 sampled residents. The facility failed to ensure Nepro supplement consumption and dialysis access site presence or absence of infection was monitored as ordered for Resident #28. Findings: Review of Resident #28's medical record revealed an initial admission date of 03/03/2023 with diagnoses which included, in part, end stage renal disease, dependence on renal dialysis, peripheral vascular disease unspecified, and chronic systolic (congestive) heart failure. Review of physician orders revealed: -10/13/2023 Dialysis schedule: resident to have dialysis 3 times a week on Monday/Wednesday/Friday at 06:30 a.m. -07/25/2023 Monitor dialysis access site to right chest wall for signs/symptoms (s/s) of infection. 0=no signs or symptoms of infection noted, 1=signs or symptoms of infection noted. Document in nurses' notes and notify MD (Medical Doctor) every shift every day. -06/24/2024 Nepro with meals Document % of intake, 1=1-25%, 2=26-50%, 3=51-75%, 4=76-100%, 5=refused. Review of May 2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (#17) out of 1 (#17) resident reviewed for respiratory services. The facility failed to ensure a physician's order was in place for Oxygen (O2) therapy and the nasal cannula and tubing were stored properly for Resident #17. Findings: Review of the facility's Oxygen Administration Policy (Concentration or Tank) undated policy revealed in part: Policy: Oxygen shall only be administered by a physician order, except in an emergency. In an emergency situation, oxygen can be administered without a physician's order, but the order must be obtained immediately after the crisis is under control . Humidifier bottles, cannula and O2 tubing will be changed at least once weekly and dated. When not in use, cannula or mask should be placed in a plastic bag. Review of Resident #17's medical record revealed an initial admit date of 10/16/2024 with diagnoses including but not limited to quadriplegia, chronic respiratory failure with hypoxia and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to administer a medication as ordered for 1 (#25) of 5 (#10, #22, #25, #27, #49) sampled residents reviewed for unnecessary medications. Findings: Review of Resident #25's medical record revealed in part an initial admission date of 08/08/2022. Further review of Resident #25's medical record revealed diagnoses including, but not limited to bipolar disorder and paranoid schizophrenia. Review of Resident #25's physician orders revealed, in part, an order dated 05/02/2025 to increase Risperdal 1 milligram (mg) to twice a day (BID). Review of Resident #25's May 2025 medication administration record (MAR) from 05/03/2025 to 05/20/2025 revealed in part, Resident #25 received Risperdal 1mg one tablet by mouth (po) at bedtime (HS). During an interview on 05/21/2025 at 9:49 a.m., S3 Licensed Practical Nurse (LPN) reviewed Resident #25's May 2025 MAR and reported Resident #25 received Risperdal 1mg po at HS. During an interview on 05/21/2025 at 11:27 a.m., S1 Director of Nursing (DON) confirmed Resident #25 had an order dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure proper infection control techniques were practiced to prevent cross contamination during incontinence care for 1 (#41) of 22 sampled residents. Findings: Review of undated Policy titled Incontinent Care: Bladder revealed: Policy: Perineal management is the cleansing of the perineal area that includes the genitalia and rectal areas. It promotes cleanliness and comfort and prevents infection by removing irritating secretions or excretions, microorganisms, and offensive odors. The care should be administered daily during bathing, and more frequently following urinary and/or fecal incontinence or if excessive secretions are present. Procedure: . 8. Put on disposable gloves. 9. For female perineal care: . b. Using the washcloth and soap or personal cleaner, wash the mans pubis, rinse and dry. c. Moisten the washcloth with water and soap or personal cleanser, and separate the labia with the thumb and finger of the nondominant hand. Wash down the center of the genitalia from the front to back, then down each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure residents' assessment accurately reflected the resident's status during the observation period for 1 (#1) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure Resident #1's MDS (Minimum Data Set) accurately reflected Resident #1's cognitive status. Findings: Review of Resident #1's medical record revealed an initial admit date of 02/11/2021 with diagnoses that included, in part, cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, other cerebrovascular disease, aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; essential (primary) hypertension, Type 2 Diabetes Mellitus, bipolar disorder and other recurrent depressive disorders. Review of Quarterly MDS with 12/05/2024 ARD (assessment reference date) revealed BIMS (Brief Interview Mental Status) was not conducted as resident was rarely/never understood. The MDS further revealed a Staff Assessment for Mental Status had been utilized to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to ensure an alleged violation of sexual abuse was reported to local law enforcement for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. Resident #1 was subject to sexual contact by S3 CNA (Certified Nursing Assistant). Findings: Review of Abuse/Neglect Prevention Program (Revised on 09/08/2021) revealed: ABUSE/NEGLECT POLICY STATEMENT The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview the facility failed to ensure the plan of care was followed for 2 (#2, #3) of 3 (#1, #2, #3) sampled residents. The facility failed to ensure physician orders were followed. Findings: Resident #2 Review of Resident #2's medical record revealed an admit date of 08/11/2017 with diagnoses that include in part: rheumatoid arthritis, chronic venous insufficiency - peripheral, long term use of insulin, and diabetes mellitus due to underlying condition with hyperglycemia. Review of Resident #2's physician orders revealed in part: 07/02/2024 Lantus Subcutaneous (SQ) Solution 100 unit/ml (milliliter) (Insulin Glargine) inject 60 units subcutaneously before meals 07/01/2024 Gabapentin Oral Capsule 300 mg (milligram) Give 1 capsule by mouth before meals 07/01/2024 Humulin R (Regular) Injection Solution, inject as per sliding scale .SQ before meals and at bedtime. Review of Resident #2's July 2024 Medication Administration Record (MAR) failed to reveal evidence the following medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure an allegation of verbal abuse by staff was reported immediately to the facility administrator and to the State Survey Agency no later than 2 hours after the allegation was made, for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. Findings: Review of the facility's Abuse/Neglect Prevention program dated March 2016 revealed, in part, the following: Reporting: Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his or her supervisor immediately. Reporting requirements: Facility must report to State Survey Agency any incidents and allegations of abuse, neglect, exploitation, misappropriation of resident property and/or injuries of unknown source immediately, but no later than 2 hours after the allegation is made, if the event that caused the allegation involves abuse or results in bodily harm. Review of resident #1's electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations and interviews the facility failed to provide services to prevent further contractures and potential decline in range of motion for 1 (#22) of 2 (#22, #26) residents reviewed for position and mobility out of a total sample of 17 residents. The facility failed to ensure hand rolls were placed for Resident #22 who had bilateral hand contractures. Findings: Review of Resident #22's medical record revealed an admission date of 03/04/2015 with diagnoses that included, in part, quadriplegia, contracture of muscle multiple sites, contracture of bilateral hands, contracture of right wrist, contracture of left wrist, muscle wasting and atrophy not elsewhere classified multiple sites. Review of Resident #22's physician orders revealed: -03/13/2023 Apply hand roll to both hands Q (every) AM. Inspect skin. May remove for baths. -03/15/2024 Remove hand rolls from both hands Q afternoon. Inspect skin. Review of Resident #22's 02/08/2024 quarterly MDS (Minimum Data Set) revealed Resident #22 was cognitively intact with a BIMS (Brief Interview Mental Status)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.