Southpark Meadows Nursing and Rehabilitation Cente

Inspectors wroteBased on record review and interview, the facility failed to ensure the required documentation in the resident's medical record made by the physician for a safe and effective transition of care 1 (Resident #1) of 5 residents reviewed for transfer or discharge. The facility discharged Resident #1 on 06/03/26 without physician documentation in the EMR. This failure could place residents at risk for inappropriate discharge resulting in psychological harm due to feelings of anger and sadness.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 5 residents reviewed for discharge planning. The facility failed to notify Resident #1 and Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, and at least 30 days before Resident #1 was discharged from the facility on 06/03/26 in a facility-initiated discharge to another skilled nursing facility. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 4 of 7 residents (Resident #59, Resident #23, Resident #46, and Resident #29) reviewed for infection control. 1. The facility failed to properly use personal protective equipment during wound care for Resident #23.2. The facility failed to follow hand hygiene procedure during direct care for Resident #59, Resident #46, and Resident #29. This failure could place residents at risk for infection transmission, sepsis, and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 4 residents (Resident #45, and Resident #105) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #45's admission MDS, dated [DATE], accurately reflected his smoking status. 2. The facility failed to ensure Resident #105's annual MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment of smoking status. Findings Included:1. Record review of Resident #45's dated 10/03/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 1 (Resident #5) of 7 residents reviewed for PASRR.The facility failed to complete an accurate PASRR level one screening after Resident #5 was admitted with a negative PASRR Level 1 screening but had a mental illness. The failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive drinks including water and other liquids consistent with need and preference and sufficient to maintain hydration for 2 of 5 residents reviewed for hydration. (Resident #s 36 and #110). The facility failed to provide water at the bedside for Resident's # 36 and # 110. On multiple occasions throughout the survey process, Resident #36's water pitcher was sitting on her nightstand (approximately 3-5 feet beyond Resident's reach). This failure placed 2 residents at risk for thirst, dehydration, UTI's, and decreased quality of life and could place the residents who were reviewed for hydration at risk for thirst, dehydration and decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized for 1 of 5 residents (Resident #86) reviewed for pharmacy services. 1. The facility did not follow up on pharmacy consultant recommendation and physician order dated 08/14/2025 to discontinue Hydroxyzine 25mg q24h prn (as needed) for Resident #86. This failure could place the residents at risk for medication errors, unnecessary medications, and incorrect administration.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of three residents reviewed for resident rights. The facility failed to notify Resident #1's NP when she was diagnosed with C. diff (a bacterium that causes diarrhea and inflammation of the colon) twice in May of 2025 which caused increased diarrhea and her laxative was not discontinued. This failure placed residents at risk of excessive diarrhea, weight loss, infection, and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to discontinue Resident #1's laxative when she was diagnosed with C. diff (a bacterium that causes diarrhea and inflammation of the colon) twice in May of 2025 which caused increased diarrhea, dehydration, elevated troponin (a protein that indicates heart damage or injury), and a weight loss of 25 pounds (27.8% weight loss) from 04/30/25 - 06/11/25. This failure placed residents at risk of an increased quality of life, weight loss, pain, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: 1. The facility failed to care plan for Resident #1's 05/11/25 orthopedic ordered left arm sling prescribed for comfort, no discontinue date. 2 The facility failed to care plan Resident #1's history of refusal of care and medication from 12/07/2024 and 05/09/25. This failure placed residents at risk of not receiving the benefit of prescribed orthopedic equipment, risk of pain and discomfort and a lack of goals and interventions for the residents' individual needs for person-centered care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 8 of 8 residents (Resident #8, Resident #11, Resident #18, Resident #38, Resident #52, Resident #62, Resident #76, and Resident #80) reviewed for resident rights. The facility failed to ensure Resident #8, Resident #11, Resident #18, Resident #38, Resident # 52, Resident #62, Resident #76 and Resident #80's call lights was within reach on 08/20/2024. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy including leaving electronic medical records out for public view for 1 (Resident #4) of 4 residents reviewed for privacy and protected HIPPA information. 1) The facility failed to ensure nursing staff locked the computer screen when it was unattended, which had displayed Resident #4's personal medical information during medication administration while RN C was away from the computer administering medication to Resident #4 at 07:56 AM on 8/16/2024. 2) On 08/20/24 at 08:13 AM RN C once again left Medication Cart A unattended and Resident #4's personal medical information open on computer screen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure that medications were secured and inaccessible to unauthorized staff and residents for 1 of 8 medication carts (Medication Cart A), and that supplies in the medication room were not expired for medication storage and labeling. 1) Facility staff failed to ensure Medication Cart A was locked while administering medications to Resident #4 at 8:13 AM on 8/16/2024. 2) On 08/20/24 at 08:13 AM staff left Medication Cart A unlocked again and left a set of keys on top of the cart. 3) Observation on 08/21/24 at 01:45 PM in the medication room revealed 12 IV Start Kits with an expiration date of 05/19/24. 4) A resident (Resident #151) had prescription medications in his room sitting on the windowsill. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 4 of 32 residents (Residents #8, #81, #206, and #217) reviewed for clinical records. 1. The facility failed to ensure a legal MPOA was in the clinical record for Resident #8. 2. The facility failed to ensure a legal OOH-DNR was in the clinical record for Resident #81. 3. The facility failed to ensure the code status for Resident #206 was evident in the clinical record. 4. he facility failed to ensure medical documents for Resident #217 were filed in the correct clinical record. This failure placed residents at risk of having their confidentiality and their rights violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who entered the facility with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #203) reviewed for catheter. The facility failed to ensure orders were entered related to Resident #203's Foley catheter at his admission on [DATE]. This failure placed residents at risk of UTI and other catheter-related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine and emergency drugs to its residents for 1 of 8 residents (Resident #206) reviewed for administration of medication. The facility failed to ensure Resident #206's medication orders were entered immediately upon his admission, and he did not receive his temazepam for insomnia his first night in the facility, 08/19/24. This failure placed residents at risk of insomnia and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #1 was administered her prescribed Clonazepam (for anxiety), Duloxetine (for depression), Zyprexa (for agitation), and Melatonin (for insomnia) for four days after admission on [DATE]. This caused her symptoms of confusion and agitation to exacerbate causing distress. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of kitchen reviewed for essential equipment. 1. The facility failed to ensure that the dishwasher dispensed the correct amount of chlorine to properly sanitize dishes. 2. The facility failed to ensure the freezer was free from leaks. 3. The facility failed to ensure the coffee machine was in good working condition. This failure could place residents at risk of being exposed to food-borne illnesses from equipment that does not function properly.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 9 of 9 residents in the confidential group interview, and one individual resident (Resident #27). Staff used cell phones in residents' presence causing residents to feel disrespected. (Resident #27 and 9 residents in the Resident Council Meeting) This failure resulted in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation.

Inspectors wroteBased on, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and the facility failed to ensure the baseline care plan was developed within 48 hours of a resident's admission for 4 of 8 residents (Residents #100, #262, #265, #267) reviewed for baseline care plan. The facility failed to ensure Resident #100 had a baseline care plan that addressed his ADL status, cognitive ability, urinary incontinence, pain management, falls or breathing treatments. The facility failed to ensure Resident #262 had a baseline care plan that addressed his PEG tube (feeding tube), diabetes mellitus, pneumonitis, ADL decline, falls, and pain. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a residents who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 (Residents #13 and#87) reviewed for indwelling catheters. The facility failed to ensure Resident #13 and Resident #87 indwelling urinary catheters were secured to prevent pulling or tugging. The failure could place residents at risk for discomfort, urethral trauma and urinary tract infections.

Inspectors wroteBased on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure that expired foods were discarded. 3. The facility failed to ensure the dishwasher dispensed the correct amount of chlorine to properly sanitize dishes. 4. The facility failed to ensure the freezer was free from leaks. 5. The facility failed to ensure the coffee machine was in good working condition. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with bed rails were assessed for the resident for risk of entrapment from bed rails, failed to provide ongoing monitoring for the use of side rails, and failed to have an order for side rails for 1 of 5 residents (Resident #7). Resident # 7 had half side rails without medical justification and a developed care plan with measurable goals benefits and risks related to side rail use. This failure could affect residents by putting them at an increased and unnecessary risk of harm, entrapment, and injury.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #100) of 5 residents reviewed for unnecessary medications. Resident #100 was prescribed an antipsychotic medication Seroquel (Quetiapine Fumarate) without a diagnosis requiring antipsychotic medication. The Facility failed to monitor Resident #100 for adverse effects of Seroquel (Quetiapine Fumarate). These failure put residents at risk of medication adverse effects as a result of being administered unnecessary antipsychotic medications.