Southside Care Center

Inspectors wroteBased on observation, interview and document review the facility failed to complete a thorough investigation of alleged abuse, provide documentation of an investigation and take action to prevent further abuse for 1 of 3 residents (R1) reviewed for abuse. This resulted in an Immediate Jeopardy (IJ) when the administrator and the director of nursing (DON) were notified of a possible sexual relationship between cook-A and R1 but failed to complete a thorough investigation prior to cook-A returning to work. The IJ began on 7/10/26, when the facility failed to conduct a thorough investigation when alleged abuse was reported. The administrator and owner were notified of the immediate jeopardy at 4:45 p.m. on 7/16/26. [...]

Inspectors wroteBased on interview, observation and document review the facility failed to maintain a clean and sanitary environment, free of pests. This had the potential to affect residents (R5, R4, R2, R6, R8) as well as all residing at the facility. This resulted in Immediate Jeopardy (IJ) when rodent feces were observed in resident rooms, resident common areas, facility kitchen and facility storage areas. The IJ began on 7/16/26, when the facility failed to take necessary action to control rodents and to make structural repairs which resulted in a rodent infestation. The administrator and owner were notified of the immediate jeopardy on 7/16/26 at 4:45 p.m. The immediate jeopardy was removed on 7/22/26, but noncompliance remained at a lower scope and severity level F, which indicated no actual harm with the potential for more than minimal harm that was not immediate jeopardy.

Inspectors wroteBased on observation and document review the facility failed to maintain medical record security and confidentiality when contents of the residents' medical records were stored in resident common area space, where residents could access the information.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment when they failed to implement housekeeping and maintenance services to install air conditioning (A/C) units in a manner that would prevent large gaps, failed to repair cracks in the exterior structure, holes in the wall and window coverings and clean the dark gray matter at the base of the walls and bottoms of the doors in the hallway, foyers and kitchen. This had the opportunity to affect all 13 residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain an environment free from fire hazards which had the potential to affect all 13 residents currently residing at the facility. In addition, the facility failed to identify resident risks and implement interventions to reduce risks and monitor a resident (R5) after an incident which included a fall off the facility premises.

Inspectors wroteBased on observation, interview and document review the facility failed to properly prepare and store food in accordance with safe food handling. This had the potential to affect all 13 residents currently residing at the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide oversight and management for the facility when there was a severe rodent infestation, lack of food, and the facility was in disrepair. This had the potential to affect all 13 residents currently residing at the facility as well as all staff and visitors.

Inspectors wroteBased on interview and document review the facility failed to establish a system to address, monitor and take actions for a known rodent problem. This had the potential to affect all 13 residents at the facility, staff and visitors.

Inspectors wroteBased on interview and document review the facility failed to ensure a sanitary environment when the facility was noted to have and failed to respond to a rodent infestation. This had the potential to affect all 13 residents currently residing at the facility as well as staff and visitors.

Inspectors wroteBased on interview and document review the facility failed to offer an interdisciplinary care conference, involve resident in the plan of care, allow the resident to share preferences or ask if they had any concerns with the care provided for 1 of 3 (R5) residents reviewed for the right to participate in care planning.

Inspectors wroteBased on interview and document review the facility failed to provide 1 of 3 (R5) residents with the Resident [NAME] of Rights (RBoR) orally or in writing upon admission to the facility.

Inspectors wroteBased on interview and document review the facility failed to notify the resident's representative following an incident involving 1 of 3 residents (R5) reviewed for notification of change.

Inspectors wroteBased on interviews and document review the facility failed to document, track and follow up with grievances filed by residents for 3 of 3 residents (R4, R2 and R3) reviewed for complaints.

Inspectors wroteBased on observation, interview and document review the facility failed to protect residents' rights to be from verbal abuse, mental abuse and neglect when cook-A verbally threatened R2 and R3, and when the facility lacked administrative supervision of staff performance.

Inspectors wroteBased on interview and document review the facility failed to immediately report abuse and abuse allegations to the State Agency (SA) within two hours for 3 of 3 (R1,R2,R3) residents reviewed for abuse. R1R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had diagnoses of endocarditis (an infection of the inner lining of heart) anxiety, depression, bipolar disorder, adjustment disorder and was cognitively intact. R1's chart lacked a vulnerability care plan. R1's progress notes lacked documentation of the alleged sexual abuse. R1's chart lacked attempts at communication to investigate alleged abuse. R2R2's quarterly MDS dated [DATE], indicated R2's diagnoses included post-traumatic stress disorder (PTSD), and anxiety. R2's cognition was intact. [...]

Inspectors wroteBased on interview and document review the facility failed to document the discharge for 1 of 3 residents (R1) reviewed for discharge process.

Inspectors wroteBased on interview and document review the facility failed to establish a baseline care plan within 48 hours of admission for 1 of 3 residents (R5) reviewed for baseline care plan.

Inspectors wroteBased on interview and document review the facility failed to develop and implement a care plan for 1 of 3 residents (R5) reviewed for care plans.

Inspectors wroteBased on interviews and document review, the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 2 of 3 residents (R5, R6) whose records were reviewed for completeness and accuracy.

Inspectors wroteBased on observation, interview and document review the facility failed to follow the established menus. This had the potential to affect all 13 residents currently residing at the facility.

Inspectors wroteBased on interview and document review the facility failed to communicate residents' food preferences to the interdisciplinary team (IDT) and failed honor residents' food preferences once those preferences were known. This had to potential to affect all 13 residents currently residing at the facility.

Inspectors wroteBased on interview and document review the facility lacked a policy for personal food storage. This had the opportunity to affect all 13 residents currently residing at the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately and consistently documented between the physician orders in the resident's electronic health record (EHR) and the Provider Order for Life-Sustaining Treatment (POLST) in the hard chart to ensure the resident's wishes would be followed in the event of a cardiac arrest. This resulted in immediate jeopardy for 2 of 13 residents (R2, R6) whose code statuses were not accurately documented, with an additional resident (R1) discrepancy found in a facility-wide audit. The immediate jeopardy began on [DATE], when interviews with the direct care nurse and director of nursing indicated they would implement incorrect procedures and not started CPR on R2 if found without a pulse and not breathing, and would have started CPR against R6's wishes under those same circumstances. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess, develop, and implement meaningful and engaging activities for 4 of 4 residents (R3, R4, R8, R9 ) reviewed who expressed concerns over a lack of activities at the facility. This had the potential to affect all 13 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to have a qualified therapeutic recreation specialist (i.e., activities director) whom was successfully qualified and/or credentialed, as required, to ensure competent assessment and implementation of activities programming within the care center. This had potential to affect all 13 residents at the time of survey.

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours each day. This had the potential to affect all 13 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly stored, dated and disposed of to reduce the risk of cross contamination and potential foodborne illnesses in the main production kitchen. In addition, the facility failed to ensure the main production kitchen refrigerator freezer unit was adequately cleaned and maintained and failed to ensure staff followed appropriate infection control techniques while preparing food when staff were observed to prepare food without a hairnet. This deficient practice had the potential to affect all 13 residents who consumed food prepared by the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive Quality Assurance and Performance Improvement (QAPI) plan was identified, implemented, and maintained to ensure acceptable levels of performance and continual improvement. In addition, the facility failed to identify and prioritize problems, such as quality deficiencies that the facility was/should have been aware of and then develop and implement appropriate actions utilizing ongoing QAPI activities. This deficient practice affected all 13 residents residing in the facility.

Inspectors wroteBased on document review and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that effectively identified and responded to quality deficiencies, and developed procedures for feedback, data collection, and monitoring systems. In addition, the facility failed to provide evidence of a Performance Improvement Project (PIP), which focused on high-risk or problem-prone areas. This deficient practice had the potential to affect all 13 residents currently residing in the facility.

Inspectors wroteBased on interview and document review, the Quality Assurance (QA) committee failed to ensure that the required members of the committee attended the meetings. This had the potential to affect all 13 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were maintained during laundry services. This had potential to affect all 13 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement an active antibiotic stewardship program which included development of protocols and a system to monitor appropriateness of antibiotic including prophylactic antibiotic use to prevent antibiotic resistance and help prevent the spread of infectious diseases. This had the potential to affect all 13 residents of facility who might use antibiotics.

Inspectors wroteDuring observation, interview and record review the facility failed to ensure facility was maintained in good repair which had the potential to affect all 13 residents, staff, and visitors of the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory resident rights training for 1 of 5 staff members (registered nurse (RN)-B) reviewed for training requirements. This had the potential to affect all 13 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory abuse/vulnerable adult training for 1 of 5 staff members (registered nurse (RN)-B) reviewed for training requirements. This had the potential to affect all 13 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory quality assurance and performance improvement (QAPI) training for 5 of 5 staff members (director of nursing (DON), registered nurse (RN)-A, RN-B, licensed practical nurse (LPN)-A, LPN-B) reviewed for training requirements. This had the potential to affect all 13 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory infection control training for 1 of 5 staff members (registered nurse (RN)-B) reviewed for training requirements. This had the potential to affect all 13 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure private and confidential resident information was secure and not visible to residents and staff members who did not require access, when documents were found stored in an unprotected manner. This had the ability to affect 9 of the 13 residents (R1, R2, R3, R4, R5, R7, R9, R10, R12) residing at the facility whose medical documents were found unprotected.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were stored in a manner to reduce the risk of unauthorized access for 5 of 5 residents (R1, R2, R3, R4, R5) observed to have medications stored in an unsecured facility refrigerator.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended influenza and pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for all 13 residents reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to establish and maintain documentation of COVID-19 vaccination status for all 13 residents of facility. In addition, facility failed to establish and maintain documentation of COVID-19 vaccination status for cook (CK)-B to include being offered and/or provided education regarding the benefits and potential risks associated with COVID-19 vaccination. This had the potential to affect all 13 residents and staff of facility.

Inspectors wroteDuring observation and interview, the facility failed to reasonably accommodate resident preference for a private and usable space for R6 who shared a room.

Inspectors wroteBased on interview and document review, the facility failed to immediately report incidents of potential resident-to-resident abuse to the state agency (SA) within two hours, as required for 2 of 2 residents (R2, R8) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure complete and comprehensive Minimum Data Set(s) (MDS) were completed for 1 of 5 residents (R7) reviewed for assessment accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure that quarterly Minimum Data Set(s) (MDS) were completed in a thorough manner for 2 of 5 residents (R1, R2) reviewed for assessment accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with the potential for inaccurate federal reimbursement and resident care planning for 2 of 5 residents (R1, R3) reviewed for MDS accuracy. Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with the potential for inaccurate federal reimbursement and resident care planning for 2 of 5 residents (R1, R3) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure timeliness of person-centered care conferences for 3 of 3 residents (R2, R4, R6) and to include periodic review and revision by an interdisciplinary team along with the residents in adjusting their care plan and making decisions about their care. Findings inclide: R2's quarterly MDS dated [DATE], indicated the BIMS was completed, and R2 had a score of 15/15, indicating intact cognition. R2's quarterly MDS dated [DATE], indicated R2 was admitted to the facility on [DATE]. The MDS indicated that the BIMS and the staff assessment for mental status were not assessed. R2's medical record was reviewed, and the last care conference note was dated 8/21/25. During an interview on 3/30/26 at 6:05 p.m., the administrator confirmed the note from 8/21/25 was the most recent care conference note he could find for R2. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to provide routine dental services to 2 of 2 residents (R3, R4) reviewed for dental services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the required nurse staffing information was posted daily and contained required information, such as the daily census and total number of licensed nursing staff working. This had the potential to affect all 13 residents residing in the facility and/or visitors who may wish to view the information.

Inspectors wroteBased on interview and document review, the facility failed to employ a registered dietician or other active qualified clinical nutrition professional to carry out the functions of a facility registered dietician. This had potential to affect 11 of 11 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service, and ensure food was properly stored and dated and disposed of. Furthermore, the facility failed to ensure staff followed appropriate infection control techniques while rinsing dirty dishes, placing clean dishes to dry, and placing items into the refrigerator. This deficient practice affected all 11 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the administration failed to provide adequate oversight, training, and guidance for appropriate resident care related to accurate Minimum Data Set (MDS) Assessments, qualified staff and related services, the pre-admission screen and resident review (PASARR) process, and Quality Assurance and Performance Improvement (QAPI) plan and Quality Assurance and Assessment (QAA) committee requirements. This deficient practice had the potential to affect all 11 residents residing in the facility, potential new admissions, visitors, and employees of the facility.

Inspectors wroteBased on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Q4), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement. Additionally, facility failed to identify and prioritize problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicators, and resident and staff input. Furthermore, the facility failed to ensure governing body oversight of the facility's QAPI program and activities. This deficient practice had the potential to affect all 11 residents residing in the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to Minimum Data Set (MDS) assessment inaccuracies, activities, trauma-informed care, food sanitation, and failure to implement a QAPI plan and maintain a QAPI committee with improvement projects which resulted in deficiencies identified during this survey. This deficient practice had the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview, and document review, the Quality Assurance (QA) committee failed to ensure required members of the committee attended the quarterly meetings. This had the potential to affect all 11 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were maintained during laundry services. This had potential to affect all 11 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This deficient practice had the potential to affect all 11 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 5 of 7 residents (R1, R6, R7, R10, R11) reviewed for inaccurate MDS assessments.

Inspectors wroteBased on interview and document review, the facility failed to ensure a level II pre-admission screen and resident review (PASARR) was completed prior to admission for 4 of 5 residents (R7, R9, R10, R11) reviewed who required a level II PASARR screening for mental illness.

Inspectors wroteBased on observation, interview, and document review, the facility failed to serve food according to a menu, and review changes to a menu with a qualified dietician or other qualified nutrition professional. In addition, the facility failed to ensure the menu met the nutritional needs of residents with a cardiac diet and other diets for 5 of 5 residents (R1, R2, R3, R5, R10) reviewed for dietary recommendations.

Inspectors wroteBased on interview and document review, the facility failed to ensure the comprehensive assessment was completed and implemented using the Resident Assessment Instrument (RAI) process as specified by CMS for 1 of 3 (R7) residents reviewed for trauma-informed care in addition to 1 of 5 residents (R7) reviewed for psychotropic medications.

Inspectors wroteBased on interview and document review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program by incorporating recommendations from the PASARR level II determination and the PASARR evaluation report into the care plan for 1 of 6 (R6) reviewed for PASARRs.

Inspectors wroteBased on interview and document review, the facility failed to review and revise the activities care plan with input from the resident and/or resident representative for 1 of 1 residents (R1) reviewed for activities.

Inspectors wroteBased on interview and document review, the facility failed to evaluate a resident's discharge needs or develop a discharge plan to ensure an appropriate discharge location could accommodate resident medical, mental health, oncology, cancer care, and medication needs for 1 of 1 residents (R12) who was discharged to a location where it was unknown if they could meet R12's needs.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 1 residents (R1) reviewed for activities.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate blood pressure monitoring and order was in place for 1 of 5 residents (R3) observed during morning medication administration.

Inspectors wroteBased on interview and document review, the facility failed to identify triggers to avoid potential re-traumatization and failed to develop and implement the comprehensive care plan to include individualized trauma-informed approaches for 1 of 2 resident (R7) who had a history of trauma.

Inspectors wroteBased on interview and document review, the facility failed to ensure a PRN (as needed) psychotropic medication order included an end date or a documented clinical rationale for 1 of 1 residents (R7) reviewed for PRN psychotropic medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the posted nurse staffing information accurately displayed the total number/actual hours worked by the licensed staff for each shift on a daily basis. This had the potential to affect all 11 residents or visitors who wished to review the information.

Inspectors wroteBased on interview and document review the facility failed to develop and implement individualized non-pharmacological interventions to manage behaviors for 2 of 2 residents (R1, R3) who had mental health disorders with behaviors. The facility's failures resulted in harm for R1 when she sustained burns from using hot towels to self-soothe to relieve anxiety symptoms and had multiple hospitalization for mental health stabilization.

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours per day. This deficient practice had the potential to affect all 13 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate wash and final rinse temperature (i.e., 150 degrees Fahrenheit (F) and 180 degrees F, respectively). This had the potential to affect all 12 residents within the nursing facility and staff who consumed food in the main production kitchen.

Inspectors wroteBased on interview and document review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement. This deficient practice had the potential to affect all 13 residents residing in the facility.

Inspectors wroteBased on document review and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that was effective in identifying and responding to quality deficiencies, and developing procedures for feedback, data collection and monitoring systems. In addition, the facility failed to provide evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas. This deficient practice had the potential to affect all 13 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to implement their infection control program and prevent and control the onset and spread of COVID-19 to the highest extent possible when R10 tested positive for COVID-19. Furthermore, the facility failed to ensure transmission-based precautions (TBP) were initiated for 6 of 6 residents (R10, R6, R5, R9, R1, R2) who tested positive for COVID-19. This had the potential to impact all residents who reside in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident showers/bathtubs were sanitary for 1 of 2 resident bathrooms reviewed for a clean, homelike environment. R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact, ambulatory, and showered independently. During interview on 11/27/23 at 7:51 a.m., R13 stated the bathtubs in both bathrooms did not get cleaned right and sometimes the residents had to clean them themselves before using them. R11's annual MDS dated [DATE], indicated she was cognitively intact, ambulatory, and showered independently. During interview on 11/27/23, at 8:29 p.m., R11 stated the bathrooms were really gross, and things didn't seem to be sanitized. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R1, R12, R13) received education and were offered or received the pneumococcal vaccine in accordance with the Centers for Disease Control (CDC) recommendations. In addition, the facility failed to obtain educated consent or refusal for 5 of 5 residents (R1, R3, R11, R12, R13) who were offered the influenza vaccine at the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess residents for the ability to self administer medications for 2 of 2 resident (R5 and R6) reviewed for medications at bedside.

Inspectors wroteBased on interview and document review, the facility failed to ensure completed Minimum Data Set (MDS) assessments were accurate for 3 of 5 residents (R2, R3, R13) reviewed for unnecessary medication.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure individualized activities were provided for 2 of 2 residents (R11, R13) reviewed for activities.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess for and identify potential triggers to avoid re-traumatization for 1 of 1 resident (R13) who had a history of trauma.

Inspectors wroteBased on observation, interview, and document review the facility failed to assess for safety and appropriate use of bed rails, ensure alternate interventions were assessed and/or attempted, and failed to review risks and benefits of bed rails and obtain consent for 1 of 1 resident (R11) who was observed to have a bed rail affixed to their bed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assist 1 of 1 residents (R6) with denture pain to obtain an appointment for dental services.