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The next survey window likely opens around November 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 Southpark Meadows Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of multiple medical conditions was diagnosed twice with C. diff, resulting in persistent and worsening diarrhea. Despite this, staff continued to administer a daily laxative and did not notify the NP of the resident's condition or medication use, contrary to the care plan and facility policy. Staff interviews confirmed awareness of the situation, but no action was taken to inform the NP or adjust treatment.
A resident with severe cognitive impairment and a history of C. diff infection continued to receive a daily laxative despite ongoing, significant diarrhea and rapid weight loss. Staff observed the resident's worsening symptoms but did not notify the NP or discontinue the medication, leading to severe dehydration, acute kidney injury, and hospitalization. Facility policies requiring physician notification for significant changes were not followed, and the resident's care plan interventions were not implemented.
A resident with hemiplegia and a history of refusing care and medication did not have a comprehensive care plan addressing an orthopedic order for a left arm sling or their repeated refusals of care. Despite staff awareness and discussion of the resident's noncompliance and preferences, these issues were not documented in the care plan, resulting in unmet needs and lack of measurable objectives or interventions.
The facility failed to ensure call lights were within reach for eight residents, violating resident rights. Observations showed call lights were often placed out of reach, preventing residents from calling for assistance. Staff interviews confirmed awareness of the requirement, but the deficiency persisted, affecting residents with various medical conditions.
A resident's privacy was compromised when RN C left electronic medical records visible on an unattended computer screen during medication administration. This occurred twice, exposing the resident's protected health information to unauthorized access. The resident, who has cognitive impairments, was unable to advocate for her privacy rights. Interviews confirmed the breach as a HIPAA violation.
A facility failed to secure medications and manage expired supplies, as observed with an unlocked medication cart and expired IV kits. A resident with cognitive impairments was involved when the cart was left unattended, and another resident had unsecured prescription medications in his room. Staff acknowledged these lapses, highlighting risks of unauthorized access and outdated supplies.
The facility failed to maintain complete and accurate medical records for four residents, leading to potential risks to their confidentiality and rights. A resident's MPOA was incomplete, another's OOH-DNR was missing, a third resident's code status was not evident, and a fourth resident's records were misfiled. These deficiencies were attributed to errors by staff, including the BOM, SW, and an LVN, and were exacerbated by a high volume of admissions and discharges.
A facility failed to enter necessary orders for a resident's indwelling catheter upon admission, leading to a lack of documented care planning. The admitting nurse did not enter catheter-related orders into the EMR, and this omission was not caught in subsequent reviews. Interviews with the DON and ADM confirmed the responsibility for entering and verifying these orders, though no immediate negative impact was observed as the resident's urine was clear and catheter placement was correct.
A resident admitted to the facility did not receive his prescribed temazepam for insomnia on his first night due to a delay in entering medication orders into the EMR. The LVN prioritized other tasks, and although the medication was later offered from the emergency kit, it was too late for the resident to take it comfortably. The DON and ADM acknowledged the need for immediate entry of medication orders to prevent such issues.
A resident did not receive her prescribed medications for anxiety, depression, agitation, and insomnia for four days after admission, leading to exacerbated symptoms of confusion and agitation. Staff noted her increased agitation and confusion, and the ADON acknowledged the responsibility to ensure medications were available upon admission. The facility's policy required clear medication orders, but the resident's medications were not administered timely, and there was a lack of documentation regarding the issue.
Failure to Notify NP of Significant Change and Continued Laxative Use During C. diff Infection
Penalty
Summary
The facility failed to immediately notify a resident's nurse practitioner (NP) when the resident experienced a significant change in physical status, specifically after being diagnosed with Clostridioides difficile (C. diff) infection on two separate occasions in May 2025. Despite the resident's care plan indicating the need to notify the physician if persistent diarrhea occurred, and lab results confirming C. diff, the NP was not informed of the increased diarrhea or the continued administration of a laxative (Bisacodyl) prescribed for constipation. The medication was given daily as per the medication administration record, even as the resident experienced worsening diarrhea. Interviews with staff revealed that the certified nursing assistant (CNA) and medication aide (MA) were aware of the resident's excessive diarrhea, and the MA expressed concern about administering the laxative but deferred to the licensed vocational nurse (LVN). The LVN acknowledged awareness of the diarrhea and the ongoing laxative order but did not notify the NP, believing it was acceptable due to the C. diff diagnosis. The director of nursing (DON) stated that nurses were expected to notify the NP immediately in such cases. The facility's policy required prompt physician notification when treatment needed to be altered due to adverse consequences.
Failure to Discontinue Laxative During C. diff Infection Resulting in Severe Weight Loss and Dehydration
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident diagnosed with C. diff on two occasions. Despite the resident experiencing persistent and severe diarrhea, the facility continued to administer a prescribed laxative (Bisacodyl) daily, as ordered for constipation, without reassessment or discontinuation. The resident's care plan included an intervention to notify the physician if persistent diarrhea occurred, but this was not done. Multiple staff members, including nursing assistants and medication aides, observed the resident's ongoing diarrhea and significant weight loss, but did not ensure that the nurse practitioner was notified or that the laxative was discontinued. The resident, who was severely cognitively impaired and always incontinent of bowel, experienced a dramatic weight loss of 25 pounds (27.8%) over approximately six weeks, as well as dehydration, elevated troponin levels, and acute kidney injury. Laboratory results confirmed repeated C. diff infections, and hospital records documented acute kidney injury, dehydration, and uremia. Interviews with staff revealed a lack of communication and follow-through regarding the resident's symptoms and weight loss, with some staff assuming others would notify the nurse practitioner or that the symptoms were expected due to the C. diff diagnosis. The facility's policies required prompt notification of the physician for significant changes in condition, including persistent diarrhea and significant weight loss, but these policies were not followed. The nurse practitioner was not made aware of the continued administration of the laxative or the extent of the resident's symptoms and weight loss. As a result, the resident continued to receive a medication that likely exacerbated her diarrhea and contributed to her decline, without appropriate clinical reassessment or intervention.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Orthopedic and Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs. Specifically, the care plan did not address the resident's orthopedic order for a left arm sling prescribed for comfort, nor did it include the resident's history of refusing care and medication. Despite multiple documented instances in the medical record of the resident refusing medications, care, and the use of the prescribed sling, these issues were not reflected in the care plan, leaving gaps in the documentation of measurable objectives and interventions tailored to the resident's needs. The resident in question was admitted with diagnoses including hemiplegia and cerebral infarction, resulting in impairment of one side of both upper and lower extremities. The resident was cognitively intact, as indicated by a BIMS score of 13, and had a documented order for a left arm sling to be used for comfort and healing. Nursing notes repeatedly documented the resident's refusals of care, medication, and the use of the sling, as well as his preferences for a specific type of sling. Interviews with staff confirmed that the resident's noncompliance and preferences were discussed in daily meetings, but this information was not incorporated into the care plan. Interviews with facility staff, including LVNs, the MDS Coordinator, the DON, and the Administrator, revealed a lack of clarity and follow-through regarding responsibility for updating care plans. While staff acknowledged that the resident's use of the sling and history of refusals should have been included in the care plan, this was not done. The facility's own policy required comprehensive care plans with measurable objectives and time frames to address all identified needs, but this was not followed in the resident's case.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for eight residents, which is a violation of resident rights. Observations and interviews revealed that the call lights for these residents were often placed out of reach, preventing them from calling for assistance when needed. This deficiency was noted for residents with various medical conditions, including dementia, Parkinson's disease, and other cognitive and physical impairments, who required substantial or maximal assistance with daily activities. For instance, Resident #76's call light was observed hanging on a privacy curtain, approximately three feet away, making it inaccessible. Similarly, Resident #38's call light was placed on a table out of reach, and Resident #52's call light was wrapped around a lowered bedrail, preventing access. Interviews with these residents confirmed that their call lights were frequently out of reach, hindering their ability to request help. Staff interviews, including those with the DON, LVN, and CNAs, indicated that they were aware of the requirement for call lights to be within reach but could not explain why this was not consistently implemented. The facility's policy on call light accessibility emphasized the importance of having call lights within reach to ensure residents' needs are met promptly. Despite this policy, the deficiency persisted, as evidenced by the observations and resident interviews.
Resident Privacy Breach Due to Unattended Medical Records
Penalty
Summary
The facility failed to ensure the privacy of a resident's personal and medical records, specifically leaving electronic medical records visible to unauthorized individuals. During medication administration, RN C left the computer screen unlocked and unattended, displaying the resident's personal medical information. This occurred on two separate occasions, once while RN C was administering medication and again when RN C left the medication cart unattended. These actions resulted in the resident's protected health information being exposed to potential unauthorized access. The resident involved was an elderly female with a history of cerebral infarction, flaccid hemiplegia, hypertension, vascular dementia, and other medical conditions. Observations revealed that the resident was unable to answer questions about her right to privacy, indicating impaired cognitive function. Interviews with RN C and the Director of Nursing confirmed the breach of privacy, acknowledging that leaving medical information visible was a violation of HIPAA regulations.
Medication Security and Expired Supplies Lapses
Penalty
Summary
The facility failed to ensure the security and proper storage of medications, as evidenced by multiple observations of an unlocked medication cart and expired supplies. On two separate occasions, staff left Medication Cart A unlocked while administering medications to a resident, with keys left on top of the cart. This oversight was acknowledged by RN A, who admitted that leaving the cart unlocked posed a risk to residents. Additionally, expired IV Start Kits were found in the medication room, indicating a lapse in monitoring and removing outdated supplies. Resident #4, who has a history of cerebral infarction, dementia, and other significant health issues, was involved in one of the incidents where the medication cart was left unattended. The resident's care plan highlighted the need for careful medication administration and monitoring due to cognitive impairments. Another resident, Resident #151, had prescription medications left unsecured on a windowsill in his room, which were brought in by a friend. This resident, who suffers from anxiety disorder and other health conditions, did not intend harm but failed to consider the potential risks of leaving medications accessible. Interviews with facility staff, including the DON and ADM, revealed acknowledgment of the lapses in medication security and expired supply management. The DON admitted to overlooking the expired IV kits and emphasized the importance of keeping medication carts locked. The ADM expressed concerns about the potential for undesirable interactions or unauthorized access to medications. The facility's policy on expiration dating and expired medications was not adhered to, as expired items were found in the medication room.
Incomplete and Misfiled Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents, leading to potential risks to their confidentiality and rights. For Resident #8, the facility did not ensure that a legal Medical Power of Attorney (MPOA) was present in the clinical record. The uploaded MPOA lacked a date, signature, and notary seal, which was attributed to a family member sending the wrong form and the Business Office Manager (BOM) uploading it by accident. This oversight could have resulted in the resident not receiving the care they desired. Resident #81's clinical record was missing a legal Out-of-Hospital Do Not Resuscitate (OOH-DNR) form, despite the resident's profile indicating a DNR status and a physician's order confirming it. The Social Worker (SW) was unsure if she was responsible for uploading the OOH-DNR, as it was typically linked to the code status order at admission. The absence of this document could have led to the resident's wishes not being observed. For Resident #206, the code status was not evident in the clinical record, as the admitting Licensed Vocational Nurse (LVN) forgot to enter it due to being busy. This omission could have delayed emergency treatment. Additionally, Resident #217's hospital records were incorrectly filed in the clinical records of two other residents, which was attributed to the high volume of admissions and discharges. This misfiling could have resulted in a violation of HIPAA or incorrect clinical information being used for patient care.
Failure to Enter Catheter Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident who entered with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and restore continence. Upon admission, the resident's baseline care plan indicated the presence of an indwelling catheter, but no specific care planning options were checked or triggered. Additionally, there were no physician orders related to the catheter entered into the electronic medical record (EMR), which was confirmed during a review of the physician's order summary. This oversight was attributed to an error by the admitting nurse, who acknowledged the importance of having catheter-related orders to inform staff of the resident's needs. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the admitting nurse was responsible for entering the orders, and the nurse management team was responsible for ensuring these orders were in place. Despite the lack of orders, the DON assessed the resident and found no immediate negative impact, as the urine was clear and the catheter placement was appropriate. However, the absence of a catheter policy and the failure to catch the omission during the morning meeting highlighted a lapse in the facility's processes for managing catheter care upon admission.
Failure to Administer Sleep Medication on Admission
Penalty
Summary
The facility failed to provide routine and emergency drugs to a resident upon admission, specifically failing to administer temazepam for insomnia on the first night. The resident, a male with multiple diagnoses including insomnia, was admitted in the evening and did not receive his prescribed sleep medication due to a delay in entering medication orders into the electronic medical record (EMR). The resident expressed dissatisfaction with the lack of communication between the hospital and the nursing facility, which resulted in him not receiving his nighttime medication and experiencing poor sleep. The Licensed Vocational Nurse (LVN) responsible for the admission prioritized other tasks over entering the medication orders, which led to the delay. Although the LVN later offered the medication from the emergency kit, it was too late for the resident to feel comfortable taking it. The Director of Nursing (DON) and the Administrator (ADM) acknowledged that the medication orders should have been entered immediately upon admission to prevent such issues. The facility's policy on entering physician orders was requested but not provided, indicating a possible gap in procedural compliance.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to a resident, resulting in the resident not receiving her prescribed medications for anxiety, depression, agitation, and insomnia for four days following her admission. The resident, who had a history of agitation, anxiety disorder, depression, stroke, and cognitive communication deficit, was admitted with specific medication orders that were not fulfilled. The resident's electronic medical record (EMR) and medication administration record (MAR) indicated that she did not receive Clonazepam, Duloxetine, Zyprexa, and Melatonin as prescribed, leading to exacerbated symptoms of confusion and agitation. Observations and interviews revealed that the resident was visibly agitated, distressed, and reported not having slept for two days. Staff members, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), noted the resident's increased agitation and confusion since her admission. The Assistant Director of Nursing (ADON) acknowledged that the nurse management team was responsible for ensuring medications were available upon admission and stated that it was unacceptable for residents to go multiple days without their medications. The ADON was unaware that the resident had been without her medications and was uncertain if the medications were available in the emergency medication kit. The facility's Medication Orders Policy required medications to be administered only upon a clear and complete order, with emergency orders necessitating direct communication between a nurse and a pharmacist. Despite this policy, the resident's medications were not administered in a timely manner, and there was a lack of documentation in the progress notes regarding the medication issue. The failure to administer the prescribed medications led to the resident's increased anxiety and agitation, as observed by the staff and documented in the progress notes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Onion Creek Nursing And Rehabilitation Center | 1.8 mi | — | 2 | 0 |
| Brodie Ranch Nursing And Rehabilitation Center | 2.6 mi | — | 3 | 1 |
| West Oaks Nursing And Rehabilitation Center | 2.8 mi | — | 13 | 0 |
| Marbridge Villa | 3.8 mi | — | 0 | 0 |
| Brush Country Nursing And Rehabilitation | 4.9 mi | — | 6 | 1 |
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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.