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 Page 1 of 2 745056 745056 01/14/2026 Southern Oaks Therapy and Living Center 3350 Bonnie View Rd Dallas, TX 75216

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 9AM, but Resident #2 stated she was good. She was unsure who answered Resident #2's call light earlier. She stated all nurses could provide incontinent care, especially when CNAs were busy.In an interview with the DON on 1/14/2026 at 1:44 PM, the DON stated CNA B was assigned to Resident #2 today, she stated CNA B should have made rounds and if she did she should know the resident was in the facility. She expected her staff to check in with residents every 2 hours and provide incontinent care every 2 hours to avoid skin breakdown and infection. She stated residents should never be left wet for more than 4 hours. She stated it would be neglect. She also stated nurses could also provided incontinent care if CNAs were busy. She provided in-services on incontinent care monthly. Record review of the facility's Abuse & Neglect policy & procedure, dated 8-10-2022, revealed neglect is defined as when a reasonable person would conclude that a deprivation of the omitted goods and services would cause, among other things, emotional distress. 745056 Page 2 of 2