Southern Oaks Therapy And Living Center

Inspection findings

1. Jun 4, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jun 12, 2026 · CMS health inspection

2. May 21, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected May 29, 2026 · CMS health inspection

3. May 7, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected May 20, 2026 · CMS health inspection

4. Apr 21, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 9, 2026 · CMS health inspection

5. Feb 15, 2026 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 2, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Mar 2, 2026 · CMS health inspection

6. Feb 6, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0627 Resident Rights Deficiencies

     Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

     Corrected Feb 23, 2026 · CMS health inspection

7. Jan 14, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Jan 23, 2026 · CMS health inspection

8. Sep 10, 2025 Health · 10 findings
   • Not serious Scope/severity E Complaint

     F0559 Resident Rights Deficiencies

     Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

     Corrected Sep 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Sep 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Sep 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Sep 30, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Sep 30, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Sep 30, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Sep 30, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Sep 30, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected Oct 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Oct 4, 2025 · CMS fire safety

9. Jun 19, 2025 Fire Safety · 1 finding
   • Not serious Scope/severity F Complaint

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jun 20, 2025 · CMS fire safety

10. May 20, 2025 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected May 21, 2025 · CMS health inspection

11. Apr 23, 2025 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0584 Resident Rights Deficiencies

      Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

      Corrected May 9, 2025 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0691 Quality of Life and Care Deficiencies

      Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

      Corrected May 9, 2025 · CMS health inspection

12. Aug 8, 2024 Fire Safety · 22 findings
    • Not serious Scope/severity F

      E0039 Emergency Preparedness Deficiencies

      Conduct testing and exercise requirements.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity D

      F0644 Resident Assessment and Care Planning Deficiencies

      Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

      Corrected Oct 31, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Sep 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Sep 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0761 Pharmacy Service Deficiencies

      Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

      Corrected Sep 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Sep 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Sep 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0921 Environmental Deficiencies

      Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

      Corrected Sep 7, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0925 Environmental Deficiencies

      Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

      Corrected Sep 7, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0223 Egress Deficiencies

      Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0293 Egress Deficiencies

      Have properly located and lighted "Exit" signs.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Nov 14, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0342 Smoke Deficiencies

      Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0374 Smoke Deficiencies

      Install smoke barrier doors that can resist smoke for at least 20 minutes.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0511 Services Deficiencies

      Have properly installed electrical wiring and gas equipment.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0741 Miscellaneous Deficiencies

      Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0761 Miscellaneous Deficiencies

      To conduct inspection, testing and maintenance of fire doors by qualified individuals.

      Corrected Sep 15, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Sep 15, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• BROWN, DEANDRE — adp of the snf, NOT APPLICABLE, since 05/01/2026
• BROWN, DEANDRE — managing control - governing body, NOT APPLICABLE, since 05/01/2026
• BROWN, DEANDRE — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 05/01/2026
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• LEO, NICHOLAS — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• LEO, NICHOLAS — managing control - governing body, NOT APPLICABLE, since 05/01/2026
• LEO, NICHOLAS — adp of the snf, NOT APPLICABLE, since 05/01/2026
• THOMPSON, JOHNNY — managing control - governing body, NOT APPLICABLE, since 05/16/2024
• THOMPSON, JOHNNY — corporate director, NOT APPLICABLE, since 05/01/2026
• BONNIE VIEW HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 05/01/2026
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 02/13/2026
• GULF PRAIRIE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 04/30/2026
• GULF PRAIRIE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• STANDARD BEARER HEALTHCARE OP, LP — adp of the snf, NOT APPLICABLE, since 05/01/2026
• THE ENSIGN GROUP INC — adp of the snf, NOT APPLICABLE, since 05/01/2026
• WEST WHARTON COUNTY HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 05/01/2026