Southern Oaks Care Center

In the surveyor’s words

From the most serious findings on record at Southern Oaks Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF755Sep 12, 2024

  Based on observation, record review, and interview, the facility failed to ensure: a. staff remained with residents until medications were taken for four (#7, 8, 16, and #23), and b. medications were administered as ordered for two (#26 and #98) of nine sampled residents reviewed for medications. The DON identified 44 residents resided in the facility. Findings: An Administering Oral Medications policy, dated October 2010, documented to remain with the resident until all medications have been taken. A. On 09/10/24 at 7:43 a.m., Resident #16 was observed at a dining room table eating breakfast. A medication cup, containing medications, was observed on the dining table next to the resident's breakfast tray. Resident #16 was observed to pour the medications into their hand. […]

• No harm, potential for more than minimal, patternF812Jul 18, 2023

  Based on observation, record review, and interview, the facility failed to: a. label and date food in the freezer, b. keep the kitchen equipment clean and have a cleaning schedule, c. log refrigerator and freezer temperatures, d. store prepared pureed food in a manner in which did not require reheating to maintain temperature, e. monitor dishwasher sanitization ppm for low temperature dishwasher, and f. ensure a dirty fan did not blow across prepared drinks and food on the steam table. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 33 residents received food from the kitchen. […]

• No harm, potential for more than minimal, patternF880Jul 18, 2023

  Based on observation, record review, and interview the facility failed to ensure: a. staff did not touch medication which they administered to a resident with their bare hands for one (#18) and b. hands were washed/sanitized in between residents during medication pass for three (#2,18, and #19) of four sampled residents observed during medication pass. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 33 residents resided in the facility. Findings: A Handwashing/Hand Hygiene policy, revised 08/15, read in parts, .This facility considers hand hygiene the primary means to prevent the spread of infection .Use alcohol-based hand rub containing at least 62 [percent] alcohol .Before and after direct contact with residents .Before preparing or handling… […]

• No harm, potential for more than minimal, patternF812Feb 2, 2022

  Based on observation, interview, and record review the facility failed to store, prepare, and serve food in a sanitary manner. The facility has 33 residents who resided in the facility. Findings: 1. On 01/31/22 at 9:15 a.m., an initial tour was conducted in the kitchen. At 9:27 a.m., the eggs observed in the refrigerator were not pasteurized. At that time the DM stated she thought they used pasteurized eggs but those were not marked pasteurized on the box. She stated they only had one resident who ate over easy eggs in the facility. At 9:35 a.m., scoops were observed in the brown and powdered sugar bins touching the product. The DM stated she was not aware scoops could not be left in the bins. At 9:41 a.m., the sanitizer was observed for the dish machine. […]

• No harm, potential for more than minimal, isolatedF628Mar 20, 2026

  Based on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation of the resident's stay and follow-up instructions were completed for 1 (#64) of 2 sampled residents who were reviewed for discharges.The DON identified one resident who had been discharged to another facility in the last three months.Findings: An undated diagnoses list showed Res #64 admitted to the facility on [DATE] with diagnoses of hypertension, chronic obstructive pulmonary disease, hyperlipidemia, and renal insufficiency. A quarterly assessment, dated 11/05/25, showed Res #64's cognition was moderately impaired with a BIMS score of 10. A discharge assessment dated [DATE], showed the resident discharged to an inpatient rehab facility on 12/26/25. […]