Southpark Meadows Nursing And Rehabilitation Center

Penalties

• Jun 6, 2025 — Fine ($10,998)

Inspection findings

1. Jun 19, 2026 Health · 2 findings
   • 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 Jun 26, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0628 Resident Rights Deficiencies

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

     Corrected Jun 26, 2026 · CMS health inspection

2. Dec 8, 2025 Health · 5 findings
   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Dec 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Dec 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0807 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

     Corrected Dec 9, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Dec 9, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 9, 2025 · CMS health inspection

3. Jun 13, 2025 Health · 2 findings
   • Serious Scope/severity H 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 14, 2025 · CMS health inspection

   • Serious Scope/severity H Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jun 14, 2025 · CMS health inspection

4. Jun 6, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 20, 2025 · CMS health inspection

5. Aug 22, 2024 Fire Safety · 9 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Feb 27, 2025 · CMS fire safety

   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     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 Sep 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Sep 20, 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 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Sep 20, 2024 · CMS health inspection

   • 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 Feb 27, 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 Feb 27, 2025 · CMS fire safety

6. May 26, 2024 Health · 1 finding
   • Serious Scope/severity H Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jun 19, 2024 · CMS health inspection

7. Jun 15, 2023 Health · 10 findings
   • Not serious Scope/severity E

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Jul 19, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jul 19, 2023 · CMS health inspection

   • Not serious Scope/severity E

     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 Jul 19, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0700 Quality of Life and Care Deficiencies

     Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

     Corrected Jul 19, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Jul 19, 2023 · 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 Jul 19, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Jul 19, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 17, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

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

     Corrected Apr 17, 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 Apr 17, 2024 · CMS fire safety

Owners and managers (as published by CMS)

• BAIRD, DANIEL — managing control - governing body, NOT APPLICABLE, since 04/13/2021
• BUNTE, MARK — managing control - governing body, NOT APPLICABLE, since 10/27/2020
• CLAPP, BARBARA — managing control - governing body, NOT APPLICABLE, since 06/01/2021
• CORTESE, DAREN — managing control - governing body, NOT APPLICABLE, since 08/10/2021
• DEKOWSKI, DONOVAN — operational/managerial control, NOT APPLICABLE, since 02/01/2015
• DEKOWSKI, DONOVAN — adp of the snf, NOT APPLICABLE, since 02/01/2015
• FLORES, RAQUEL — adp of the snf, NOT APPLICABLE, since 01/01/2025
• FULCHER, ANN — managing control - governing body, NOT APPLICABLE, since 01/22/2015
• GIBSON, PATRICIA — managing control - governing body, NOT APPLICABLE, since 08/01/2021
• GUTIERREZ, MICHAEL — adp of the snf, NOT APPLICABLE, since 02/01/2015
• MANDELBAUM, ELLIOT — managing control - governing body, NOT APPLICABLE, since 01/01/2025
• NIITZEL, KIMBERLY — adp of the snf, NOT APPLICABLE, since 01/01/2025
• STRONG, TYLER — operational/managerial control, NOT APPLICABLE, since 01/21/2019
• STRONG, TYLER — adp of the snf, NOT APPLICABLE, since 01/21/2019
• WILSON, LINDA — corporate officer, NOT APPLICABLE, since 07/19/2023
• WILSON, LINDA — managing control - governing body, NOT APPLICABLE, since 07/19/2023
• 9801 SOUTH FIRST STREET LLC — adp of the snf, NOT APPLICABLE, since 02/01/2015
• CSV RHEA MANAGEMENT HOLDCO, LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2015
• DWD TX HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2015
• JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC — indirect ownership interest, NOT APPLICABLE, since 02/01/2015
• REG BRIDGE OPCO LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2015
• REG HG OPCO LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2015
• REG OPERATOR HOLDCO LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2015
• REGENCY IHS CLINICAL CONSULTING, LLC — adp of the snf, NOT APPLICABLE, since 02/01/2015
• REGENCY IHS OF SOUTHPARK MEADOWS, LLC — adp of the snf, NOT APPLICABLE, since 06/23/2025
• REGENCY IHS OF SOUTHPARK MEADOWS, LLC — direct ownership interest, NOT APPLICABLE, since 02/01/2015
• REGENCY IHS REHAB LLC — adp of the snf, NOT APPLICABLE, since 02/01/2015
• REGENCY INTEGRATED HEALTH SERVICES LLC — adp of the snf, NOT APPLICABLE, since 04/28/2025
• REGENCY INTEGRATED HEALTH SERVICES LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2015
• REGENCY INTEGRATED HEALTH SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 02/01/2015
• REGENCY TEXAS HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 02/01/2015
• SMITHVILLE HOSPITAL AUTHORITY — operational/managerial control, NOT APPLICABLE, since 02/01/2015
• SMITHVILLE HOSPITAL AUTHORITY — 5% or greater direct ownership interest, 100%, since 02/01/2015
• SMITHVILLE HOSPITAL AUTHORITY — adp of the snf, NOT APPLICABLE, since 06/23/2025