Southern Oaks Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 17, 2025

  Based on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from a staff member for 1 (Resident #1) of 3 (Resident #1, #2, #3) sampled residents. The facility failed to ensure S3 CNA (Certified Nursing Assistant), Resident #1's primary CNA and caregiver, did not commit abuse of power when she engaged in sexual relations with Resident #1 in his bed. The deficient practice resulted in an Immediate Jeopardy on 03/01/2025 at approximately 5:50 a.m., when S4 CNA entered Resident #1's room and witnessed S3 CNA, Resident #1's primary caregiver, on top of Resident #1 having intercourse in Resident #1's bed. […]

• Immediate jeopardy, isolatedF607Mar 17, 2025

  Based on record review and interviews the facility failed to develop and implement written policies and procedures that included immediate response to protect an alleged victim from physical and psychosocial harm during and after an investigation. The facility failed to ensure Resident #1 was provided immediate protections after S4 CNA (Certified Nursing Assistant) witnessed S3 CNA engaging in sexual relations with Resident #1. The deficient practice resulted in an Immediate Jeopardy on 03/01/2025 at approximately 5:50 a.m., when S4 CNA entered Resident #1's room and witnessed S3 CNA, Resident #1's primary caregiver, on top of Resident #1 having intercourse in Resident #1's bed. S4 CNA immediately left out of Resident #1's room and did not provide immediate protection to Resident #1. […]

• Immediate jeopardy, isolatedF835Mar 17, 2025

  Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #1) of 3 (Resident #1, #2, and #3) residents reviewed for abuse. The facility failed to have an effective system in place to: 1. Protect Resident #1 from abuse of power by S3 Certified Nursing Assistance (CNA) when S3 CNA sexually abused Resident #1 on 03/01/2025, 2. Provide immediate protection to Resident #1, and 3. […]

• Actual harm, isolatedF600May 22, 2024

  Based on record review and interview, the facility failed to protect the resident's right to be free of verbal abuse and psychosocial harm by facility staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for resident #1 who was cognitively impaired with communication deficits on 04/23/2024 when S3CNA (certified nursing assistant) verbally abused resident #1 by telling resident #1, I will hit you in your m__f__ face, during resident #1's whirlpool bath. Resident #1 was agitated during the bath and did not want his hair washed by S3CNA. […]

• No harm, potential for more than minimal, patternF812Aug 5, 2026

  Based on record review and interview the facility failed to maintain, store, prepare, distribute, and serve food under sanitary conditions. The facility failed to monitor and maintain freezer temperatures. This had the potential to affect the 55 residents who were served trays out of the kitchen according to S3 Dietary Manager. Findings:Review of policy titled Storage of Frozen Food (revised 10/18) revealed:POLICY:The facility ensures the quality and safety of frozen through accepted storage practices.PROCEDURE: .1. Frozen food is stored in a freezer to keep the food solidly frozen (<20F [Fahrenheit].) .10. Food temperatures are regularly monitored and recorded. Corrective action is taken as indicated. […]