Health inspection·January 14, 2026

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included:Record review of Resident #2's face sheet, dated 1/14/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included brain bleed, back pain and type 2 diabetes.Record review of Resident #2's MDS assessment, dated 10/14/2025, revealed her BIMS score was 15, which indicated the resident was cognitively intact.Record review of Resident #2's progress note, dated 1/13/2026 at 11:30 PM, revealed the resident returned to facility via ambulance service.Record review of Resident #2's care plan, dated 1/14/2026, revealed she was on antibiotic therapy for urinary tract infections. The Care plan also revealed she had bladder incontinence and one of the interventions listed was to check as required for incontinence.In an interview on 1/14/2026 at 11:11 AM, Resident #2 stated she got back from the hospital at midnight and she was provided incontinent care around 4 or 5 AM this morning. She said she had not been changed yet and it's causing her distress because she was sitting in wet brief She stated she was not usually at the facility in the mornings because she saw therapy every morning at another location. She was at the facility this morning because she just got discharged from the hospital. She stated she would push the call light to ask to be changed after the interview with state surveyor.In an observation and interview on 1/14/2026 at 12:50 PM, Resident #2 was still left unchanged. She stated it had been more than 7 hours since Resident #2 was last changed. She stated she pushed the call light about an hour ago and a nurse answered the call, and stated she would get an aide to help, but Resident #2 stated nobody had been back to change her since then. She stated she could not recall the nurse's name. She stated the nurse was usually sitting by the nurse station. In an interview on 1/14/2026 at 1:00 PM, CNA B stated she was assigned to Resident #2 today. She stated she had not checked in with Resident #2 yet. She stated she believed the resident just got back from the hospital about 2 hours ago. She stated she came in at 6AM this morning and she had not yet made rounds to see Resident #2 because she was busy. She stated she checked in with residents every 2 to 3 hours to ensure they were safe and their needs were met. She stated the risk of not changing residents every 2 hours included skin breakdown and infections.In an interview with RN D on 1/14/2026 at 2:05 PM, she stated she made rounds every morning and as needed. She was assigned to Resident #2 today. She stated CNAs were expected to make rounds every 2 to 3 hours. She stated residents should be changed every 2 hours or if they were wet or soiled. She stated the risks of leaving residents wet or soiled, more than 2 hours included infections, pressure sores and skin breakdown. She stated she answered Resident #2's call light after breakfast around (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 745056 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 745056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Oaks Therapy and Living Center 3350 Bonnie View Rd Dallas, TX 75216 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)