Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Park East during CMS and state inspections, most recent first.
Multiple residents with severe cognitive impairment and dementia experienced repeated incidents of inappropriate sexual contact from other residents known to have sexually inappropriate behaviors. Despite prior interventions such as medication and 1:1 supervision, the facility did not consistently update care plans or ensure staff were adequately trained in abuse prevention, resulting in ongoing incidents and insufficient communication with families.
The facility did not thoroughly investigate or document multiple allegations of inappropriate sexual contact between residents. There was no evidence of safety assessments for other potentially affected residents, and abuse education for staff was not documented. The DON confirmed that investigation summaries were not completed and that staff education was only provided verbally.
A resident with severe cognitive impairment and dementia was involved in an incident of inappropriate contact by another resident. Although facility records indicated the family was notified, the family reported being unaware of the incident, and the DON confirmed only one unsuccessful attempt to reach them was documented, with no follow-up.
A resident with severe cognitive impairment and sexual dysfunction engaged in multiple incidents of sexually inappropriate behavior, but the care plan was not updated promptly after each event as required by facility policy. The MDS coordinator confirmed delays in care plan revisions following these incidents.
Failure to Protect Residents from Sexual Abuse and Inadequate Abuse Prevention Measures
Penalty
Summary
The facility failed to protect residents from sexual abuse and inappropriate touching, resulting in multiple incidents involving residents with severe cognitive impairment and dementia. Several residents with a history of sexually inappropriate behaviors were observed touching other residents inappropriately on multiple occasions. These incidents occurred despite the residents being known to have sexual dysfunction and behavioral issues, and despite previous interventions such as medication and 1:1 supervision. Documentation showed that after each incident, the involved residents were placed on 1:1 supervision, but the care plans were not always updated in a timely manner to reflect the current status or interventions. Staff interviews revealed inconsistent knowledge and implementation of abuse prevention protocols. Some CNAs and an LPN reported that their primary intervention was to redirect the resident and initiate 1:1 supervision, but they were not always aware of additional steps taken or required. There was also a lack of consistent and recent abuse education among staff, with some staff members stating they had not received abuse training in the weeks leading up to the incidents. The DON acknowledged that efforts to prevent recurrence included monitoring and attempting to keep residents separated, but there was no documentation that families were always notified of incidents involving their loved ones. Medical records and staff statements confirmed that the residents involved had severe cognitive impairment, with BIMS scores indicating significant deficits. The facility's own policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the incidents described met this definition. Despite the known risks and previous behaviors, the facility did not ensure adequate protection for all residents, as evidenced by repeated incidents of inappropriate sexual contact and insufficient updates to care plans and communication with families.
Removal Plan
- Identify total number of residents at risk for the same failed practice.
- Place affected residents on 1:1 supervision following incidents.
- Increase psychoactive medications for affected residents as ordered by the PA after incidents.
- Change resident’s room to reduce proximity to women.
- Send resident to the hospital for psychological evaluation after incident and maintain 1:1 supervision upon return.
- Maintain affected residents on 1:1 supervision after incident.
- Notify the PA of each incident and implement medication changes/interventions as directed.
- Interview all interviewable residents and assess non-interviewable residents for evidence of abuse or inappropriate/nonconsensual contact.
- Provide in-service training for all staff on abuse/neglect risk, sexual behaviors, identification of those at risk, protection measures, and dementia care, including documentation of 1:1 supervision.
- Require all current staff to complete in-service training before their next scheduled shift; no staff permitted to work until trained.
- Implement ongoing monitoring of resident behaviors to observe for potential to administer/receive abuse or neglect, including sexual abuse.
- Screen new admissions through interviews and record reviews for at-risk behaviors, including abuse/neglect and sexual behaviors.
- Care plan at-risk residents with individualized interventions, including possible 1:1 supervision and/or safe discharge, and document on baseline and regular care plans.
- Capture behaviors in behavior notes and screen daily by the DON or designee to identify behaviors that might lead to abuse/neglect, including sexual behaviors.
- Require staff to notify the DON or Administrator immediately of residents exhibiting increased sexuality or behaviors putting others at risk so immediate intervention can be placed.
- Add Psych Plus services to the facility’s service offerings.
- DON or designee to conduct daily review of all incidents and behavior notes to identify residents at risk for behaviors affecting others, including abuse/neglect and sexual behaviors.
- Continue staff training on dementia care, protective measures from abuse/neglect, behavior prevention/management, and documentation for 1:1 care, including for new hires.
- Administrator or designee to monitor abuse/neglect identification, protection from abuse/neglect, and dementia care, including behaviors that put self or others at risk.
- Daily review of allegations, incidents, and behaviors that put or potentially put self or others at risk, as well as documentation for 1:1 supervision.
- Carry information through the Quality Assurance Performance Improvement (QAPI) process.
- Ensure all residents that can be interviewed are interviewed and non-interviewable residents are assessed for evidence of abuse or inappropriate/nonconsensual contact.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving five residents. Multiple incident reports documented inappropriate sexual contact between residents, including instances where one resident touched the breast of other residents. Despite these reports, there was no evidence that the facility conducted or documented safety assessments of other residents who may have been affected. Additionally, the facility did not provide or document abuse education for all staff following these incidents, as required by their own policy. Interviews with the DON revealed a lack of awareness regarding the completion of investigation summaries on incident reports and confirmed that staff education on abuse was not formally documented, but only provided verbally. The DON also stated that assessments of potentially affected residents were performed visually and not documented. These actions and omissions resulted in a failure to ensure that all alleged violations were appropriately responded to and thoroughly investigated.
Failure to Notify Family of Abuse Allegation
Penalty
Summary
The facility failed to notify a resident's family of an allegation of abuse involving the resident. According to facility policy, the resident, their attending physician, and their representative are to be promptly notified of changes in the resident's condition or status. Record review showed that a resident with severe cognitive impairment and diagnoses including Alzheimer's disease and dementia was involved in an incident where another resident was observed touching them inappropriately. Although documentation indicated that the family was notified, an interview with the family revealed they were not aware of the incident or any related events. The Director of Nursing confirmed that there was only a single, unsuccessful attempt to contact the family, with no documented follow-up or successful notification.
Failure to Timely Update Care Plan After Abuse Incidents
Penalty
Summary
The facility failed to timely revise and update the care plan for a resident following multiple incidents of abuse. According to the facility's policy, care plans must be revised as information about the resident and their condition changes, and the interdisciplinary team is required to review and update the care plan when desired outcomes are not met. In this case, a resident with severe cognitive impairment and a diagnosis of sexual dysfunction was involved in several incidents of sexually inappropriate behavior, including grabbing staff and making sexual comments. Although the care plan was initially created and later revised, documentation showed that updates were not made promptly after each incident as required. Record review and staff interviews revealed that incidents occurring on specific dates were not reflected in the care plan until several days later. The MDS coordinator acknowledged that care plans were typically updated every three months and as necessary, but admitted that updates for certain incidents were delayed. The coordinator also confirmed that they were solely responsible for updating care plans and recognized that the care plan should have been updated sooner following the incidents of abuse.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Care Center Southwest Llc | 1.5 mi | — | 1 | 0 |
| Capitol Hill Skilled Nursing And Therapy | 2.5 mi | — | 0 | 0 |
| South Pointe Rehabilitation And Care Center | 2.8 mi | — | 0 | 0 |
| Accel At Crystal Park | 3 mi | — | 6 | 1 |
| Brookwood Skilled Nursing And Therapy | 3.4 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.