Inspection Reports for Southpark Meadows Nursing and Rehabilitation Center
9801 S 1st St, Austin, TX 78748, TX, 78748
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
66% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify the resident's physician of a significant change in physical status and failure to discontinue a laxative for Resident #1 diagnosed with C. diff, leading to increased diarrhea and other health complications.
Complaint Details
The complaint investigation found substantiated failures in notifying the nurse practitioner about Resident #1's increased diarrhea and continued laxative use, which contributed to dehydration, weight loss, and hospitalization. Interviews with Resident #1's responsible party, nurse practitioner, nursing staff, and director of nursing confirmed these issues.
Findings
The facility failed to notify Resident #1's nurse practitioner about her C. diff diagnoses and continued administration of a laxative, resulting in increased diarrhea, dehydration, significant weight loss, elevated troponin levels, and hospitalization. Interviews with staff and family confirmed lack of timely communication and inadequate treatment adjustments.
Deficiencies (3)
Failure to immediately notify the resident's physician of significant change in physical status.
Failure to discontinue laxative medication despite diagnosis of C. diff causing increased diarrhea and weight loss.
Failure to provide appropriate treatment and care according to orders and resident's preferences.
Report Facts
Weight loss: 25
BIMS score: 3
Troponin level: 0.94
Creatinine level: 2.3
BMI: 16.53
Dates of C. diff diagnosis: Diagnosed on 05/11/25 and 05/28/25.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Aware of Resident #1's increased diarrhea and laxative use but did not notify NP. |
| MA B | Medical Assistant | Administered laxative despite knowing Resident #1 had diarrhea and expressed concern to LVN C. |
| CNA A | Certified Nursing Assistant | Observed Resident #1's excessive diarrhea and frequent brief changes. |
| DON | Director of Nursing | Expected nurses to notify NP immediately of excessive diarrhea or weight loss; acknowledged failure in notification. |
| NP D | Nurse Practitioner | Not notified of Resident #1's increased diarrhea or continued laxative use; stated she would have discontinued laxative. |
| NP E | Nurse Practitioner | Covering for NP D; confirmed significant weight loss and elevated troponin could result from prolonged diarrhea. |
| Resident #1's PCP | Primary Care Physician | Stated laxative may have contributed but was not cause of all ER diagnoses; no negligence found. |
Inspection Report
Deficiencies: 2
Date: Jun 6, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on the development and implementation of comprehensive person-centered care plans for residents.
Findings
The facility failed to develop and implement a comprehensive care plan for Resident #1 that included measurable objectives and timetables, particularly regarding the prescribed left arm sling and the resident's history of refusal of care and medication. This failure placed residents at risk of inadequate care and discomfort.
Deficiencies (2)
Failed to care plan for Resident #1's 05/11/25 orthopedic ordered left arm sling prescribed for comfort, with no discontinue date.
Failed to care plan Resident #1's history of refusal of care and medication from 12/07/2024 and 05/09/25.
Report Facts
Residents reviewed for care plans: 5
BIMS score: 13
Medication dosage: 30
Medication dosage: 12
Insulin units: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in multiple progress notes documenting Resident #1's refusals of care and medication |
| LVN B | Licensed Vocational Nurse | Interviewed regarding Resident #1's sling usage and care plan responsibilities |
| Administrator | Facility Administrator | Interviewed about care plan responsibilities and the importance of including Resident #1's sling in the care plan |
| DON | Director of Nursing | Interviewed about Resident #1's sling usage, care plan responsibilities, and non-compliance discussions |
| LVN/MDSC | Licensed Vocational Nurse/Minimum Data Set Coordinator | Interviewed about care plan updates and responsibilities |
| NP | Nurse Practitioner | Interviewed regarding Resident #1's left arm fracture and sling compliance |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, privacy, medication administration, catheter care, medication security, and clinical record maintenance at Southpark Meadows Nursing and Rehabilitation Center.
Findings
The facility failed to ensure call lights were within reach for 8 residents, maintain resident privacy by securing electronic medical records, provide appropriate catheter care orders for a resident, ensure timely medication order entry and administration, secure medications and supplies properly, and maintain complete and accurate clinical records for several residents.
Deficiencies (6)
Failed to ensure call lights were within reach for 8 residents, risking unmet needs.
Failed to secure electronic medical records, leaving resident information visible and violating HIPAA.
Failed to enter catheter orders for Resident #203 at admission, risking UTI and complications.
Failed to provide routine and emergency drugs timely; Resident #206 did not receive temazepam on admission night.
Failed to ensure medication cart was locked and supplies were not expired; medications found unsecured in resident room.
Failed to maintain complete and accurate clinical records including legal MPOA, code status, and correct filing of documents for multiple residents.
Report Facts
Residents affected by call light deficiency: 8
Expired IV Start Kits: 12
Medication carts observed: 8
Residents reviewed for clinical records: 32
Residents reviewed for medication administration: 8
Residents reviewed for catheter care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Left Resident #4's medical information visible on computer screen and left Medication Cart A unlocked | |
| LVN A | Interviewed about call light responsibility and medication security | |
| DON | Director of Nursing | Provided multiple interviews regarding call light, medication security, catheter orders, and clinical record issues |
| CNA F | Interviewed about call light placement and resident safety | |
| ADM | Administrator | Interviewed about medication security, clinical record issues, and overall facility compliance |
| LVN D | Admitting nurse responsible for Resident #203 catheter orders | |
| LVN E | Admitted Resident #206 and responsible for medication order entry | |
| SW | Social Worker | Discussed uploading of legal documents and clinical record maintenance |
| MR | Medical Records staff | Uploaded hospital documents to wrong resident charts |
| BOM | Uploaded MPOA document for Resident #8 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide pharmaceutical services to meet the needs of Resident #1, specifically the failure to administer prescribed medications for four days after admission.
Complaint Details
The visit was complaint-related, substantiated by findings that Resident #1 did not receive prescribed medications for four days, causing increased anxiety, agitation, and confusion.
Findings
The facility failed to administer prescribed medications Clonazepam, Duloxetine, Zyprexa, and Melatonin to Resident #1 for four days after admission, resulting in increased confusion, agitation, and distress. Interviews and record reviews confirmed the delay in medication administration and the resident's worsening symptoms.
Deficiencies (1)
Failure to provide pharmaceutical services to meet the needs of Resident #1 by not administering prescribed medications for four days after admission.
Report Facts
Days without medication: 4
BIMS score: 11
Medication doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Documented progress notes and provided interview regarding Resident #1's condition and medication status. |
| LVN D | Licensed Vocational Nurse | Marked medication administration records and was contacted multiple times without return call. |
| CNA C | Certified Nursing Assistant | Provided interview about Resident #1's increased confusion and agitation since admission. |
| ADON | Assistant Director of Nursing | Provided interview about nurse management responsibilities and medication availability. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Southpark Meadows Nursing and Rehabilitation Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 7
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food safety, equipment maintenance, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to develop baseline care plans within 48 hours of admission for several residents, improper catheter care, lack of assessment and orders for bed rail use, unnecessary use of psychotropic medication without proper diagnosis or monitoring, and multiple food safety and equipment maintenance issues in the kitchen.
Deficiencies (7)
Failure to treat residents with respect and dignity, including staff use of cell phones in residents' presence causing residents to feel disrespected.
Failure to develop and implement baseline care plans within 48 hours of admission for 4 of 8 residents reviewed.
Failure to provide appropriate care for residents with indwelling urinary catheters, including failure to secure catheters to prevent pulling or tugging for 2 of 3 residents reviewed.
Failure to assess residents for risk of entrapment from bed rails, failure to provide ongoing monitoring, and failure to have an order for side rails for 1 of 5 residents reviewed.
Failure to ensure psychotropic drug regimen was free from unnecessary medications and failure to monitor for adverse effects for 1 of 5 residents reviewed.
Failure to store, prepare, distribute, and serve food in accordance with professional standards including unlabeled and expired foods, dishwasher not sanitizing properly, freezer leaks, and coffee machine leaking.
Failure to maintain all mechanical, electrical, and patient care equipment in safe operating condition including dishwasher sanitizer issues, freezer leaks, and coffee machine malfunction.
Report Facts
Residents affected: 9
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Chlorine level in dishwasher: 10
Chlorine level in dishwasher log: 50
Food items expired: 4
Freezer leak depth: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #27 | Resident | Interviewed about staff cell phone use and feelings of disrespect |
| Administrator | Interviewed regarding ongoing cell phone use issues and equipment maintenance | |
| DON | Director of Nursing | Interviewed regarding baseline care plan failures, cell phone use, bed rail assessments, and psychotropic medication monitoring |
| CNA A | Certified Nursing Assistant | Interviewed regarding catheter care for Resident #13 |
| LVN B | Licensed Vocational Nurse | Interviewed regarding catheter care for Resident #13 |
| LVN C | Licensed Vocational Nurse | Interviewed regarding catheter care for Resident #87 |
| Dietary Aid D | Dietary Aid | Interviewed regarding kitchen sanitation issues including expired foods and dishwasher sanitizer levels |
| Dietary Aid E | Dietary Aid | Interviewed regarding dishwasher sanitizer levels |
| Food Service Manager | Food Service Manager | Interviewed regarding kitchen sanitation and equipment maintenance |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding freezer leak and coffee machine repair |
Inspection Report
Routine
Deficiencies: 4
Date: Apr 29, 2022
Visit Reason
The inspection was conducted to assess compliance with care planning, respiratory care, and environmental safety standards in the nursing home.
Findings
The facility failed to develop and implement comprehensive person-centered care plans for several residents, including missing care plans for advance directives, communication deficits, and oxygen therapy management. Additionally, the facility did not maintain a safe and sanitary environment, exemplified by a resident's dirty refrigerator. These deficiencies could result in missed or inappropriate care and potential health risks.
Deficiencies (4)
Failed to develop and implement a complete care plan that meets all the resident's needs, including advance directives, communication problems, and diabetes for Resident #63.
Failed to review and revise care plans after assessments for Residents #30 and #60, including bowel incontinence and oxygen therapy behaviors.
Failed to provide safe and appropriate respiratory care for Residents #37 and #60, including oxygen administration without physician orders and incorrect oxygen settings.
Failed to maintain a safe, functional, sanitary, and comfortable environment; Resident #3's room refrigerator was dirty, with grime, undated food containers, and leaking melted water.
Report Facts
Deficiencies cited: 4
Oxygen rate: 3
Oxygen rate: 3
Temperature: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS B | MDS Coordinator | Responsible for developing comprehensive care plans; admitted missing care plans for Resident #63 and #60. |
| Social Worker | Responsible for developing advance directives care plan for Resident #63; admitted missing the care plan. | |
| CNA H | Certified Nursing Assistant | Provided care to Resident #63; unaware of diabetes diagnosis and lacked access to care plans. |
| DON | Director of Nursing | Acknowledged missing care plans and oxygen management issues; responsible for oversight. |
| LVN A | Licensed Vocational Nurse | Charge nurse; admitted not checking oxygen orders and rates for Residents #37 and #60. |
| LVN E | Licensed Vocational Nurse | Referred to physician orders and MARS for Resident #63; noted dirty refrigerator. |
| CNA D | Certified Nursing Assistant | Commented on dirty refrigerator in Resident #3's room. |
| Housekeeping F | Admitted not cleaning Resident #3's refrigerator; responsible for cleaning refrigerators. | |
| Housekeeping G | Had not been instructed to clean resident refrigerators. | |
| Facility Administrator | Acknowledged lack of policy or schedule for cleaning resident refrigerators. |
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