Southside Care Center
Southside Care Center in MINNEAPOLIS, MN — inspection on April 6, 2026.
Found 27 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
private and usable space for R6 who shared a room.Findings include:R6's quarterly MDS dated
diagnoses of depression, diabetes, anxiety, and post-traumatic stress disorder.During observation on 3/30/26 at 1:15 p.m., R6 was lying in his bed in his two-person room. R6's twin sized bed was located inside the door frame to the hallway.
The bed was parallel to and against the North wall of room.
The footboard of his bed was against a closet which extended from North wall by 20 inches. A privacy curtain attached to the ceiling started at the closet above the foot of his bed and draped around a dresser which measured 18 inches deep by 30 inches long.
The curtain was pulled out to encompass the dresser and then immediately parallel and against R6 bed to the head of his bed and [NAME] wall.
There was no carpet or floor area for R6 to stand in that was inside the curtained or privacy area making it impossible to obtain his clothes and get dressed without standing outside the privacy curtain. R6's bed measured 46 inches by 96 inches for a total of 30.67 square feet of space enclosed by privacy curtain. R6 stated, my area is the smallest [in the facility].
Curtain goes around my bed and that is all. R6 stated he would like my space in this bedroom to be much bigger but there ain't a bigger space so I have to deal with this.During observation and interview with administrator on 4/2/26 at 9:54 a.m., the administrator verified measurements of R6's privacy curtain and agreed that the curtain wrapped around the bed with no floor space to stand or move unless [R6] was outside the curtained area.During observation and interview with director of nursing (DON) on 4/6/26 at 11:11 a.m., DON looked at R6's room and stated that is not enough room to move around privately in [R6's] room.
There is barely any floor to walk on inside the privacy curtain.During interview with co-owner (O)-O of facility on 4/6/26 at 1:36 p.m., O-O stated facility was licensed for 17 beds and there were concerns that the rooms are tight. O-O stated R6's personal space provided by the privacy curtain in his shared room was, much tighter than I would like in my room. I did not take into account the usable square foot for [R6].
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jeopardy to resident health or and implemented a systematic removal plan.
The removal plan was verified through interview and safety document review as the facility corrected the code status' of R2 and R6, completed a facility-wide audit to ensure there were no other code status discrepancies and corrected any that weren't
education for all staff involved in ensuring advance directives were honored on the CPR and POLST policies/procedures and their respective roles in the process.
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During interview with administrator on 4/1/26 at 2:52 p.m., administrator stated, private information should not be left out in the open. It should be filed away into the computer or downstairs filing cabinet.
The med lists and pharmacy order forms and all that information in the dining room is not private and can be seen by anyone who wants to look. It is not secured.
During interview with R11 on 4/2/26 at 8:24 a.m., R11 stated no one should see my personal information unless I want them too. My identity is my own and no one's[sic] business to snoop or see my health care stuff.
During interview with R9 on 4/2/26 at 8:26 a.m., R9 stated, My health care information is my own. No one has the right to look at it. I would be upset if my personal information was out in the open for anyone to see.
That is how identity theft occurs.
During interview with R6 on 4/2/26 at 8:27 a.m., R6 stated, It would make me very, very angry if anyone were able to see my private information like diagnosis and meds.
That ain't right.
Facility policy titled, Protected Health Information (PHI), Management and Protection of, revised April 2014 identified: It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.
The facilities Release of Information policy dated 11/2009, indicated that each resident would receive confidential treatment of his or her personal and medical records.
The policy indicated that access to the residents' medical records would be limited to the staff and consultants providing services to the residents.
The policy indicated that closed or thinned medical records would be maintained in the medical records department and should be available only to authorized personnel, including: nursing staff, physicians, consultants, support services such as dietary, activities, and social, administrator, government agencies, and the resident/resident representative.
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authorities.
interview and document review, the facility failed to immediately report incidents of potential
(R2, R8) reviewed for abuse.Findings include:R2R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated the Brief Interview for Mental Status (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 completed.
The MDS indicated R2 was diagnosed with anxiety and depression.R2's progress notes were reviewed and lacked an indication that R2's allegations of resident-to-resident abuse were reported to the SA.R8R8's admission MDS dated [DATE], indicated that R8 had intact cognition and had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) one to three days during the look back period (LBP).
The MDS indicated R8 was diagnosed with schizophrenia. R2's and R8's MDS data were reviewed, and indicated they resided in the same room.R8's progress note dated 3/30/26 at 5:59 a.m., indicated R8 was observed taking cigarettes from her roommate without permission and became verbally aggressive toward the roommate, including name-calling and threatening to physically fight her.R8's progress note dated 3/31/26 at 1:20 p.m., indicated R8 was currently experiencing significant behavioral disturbances and paranoid delusions, including accusations that others had poisoned her or harmed her father.
The note indicated these symptoms frequently manifested as verbal aggression, as she would direct death threats and profanity towards staff when her hourly demands for cigarettes were not met.
The note indicated R8's behaviors had profoundly impacted her roommate, whom she targeted with disparaging remarks about her critically ill mother, leading to significant emotional distress. R8's progress notes were reviewed and lacked an indication that R2's allegations of resident-to-resident abuse were reported to the SA.R8's progress note dated 4/1/26 at 12:11 a.m., indicated R8 had been transferred to the hospital after appearing visibly agitated, internally preoccupied, and making suicidal statements, including verbal threats of self-harm.
During an interview on 3/30/26 at 1:25 p.m., R2 stated she had trouble with her roommate. R2 stated she had been roommates with R8 since February and didn't have any issues until recently. R2 stated recently that R8 had been calling her a fat (expletive), threatening her, and asking to fight her. R2 stated she does not feel safe living with R8.
R2 stated staff were aware of R8's behaviors toward her and were trying different things to help, checking on her often, and offered to let her move rooms, but she did not want to.
During a follow-up interview on 4/1/26 at 10:58 a.m., R2 stated R8 had said a lot of vile nonsense to her yesterday. R2 stated R8 had stolen her phone from her and thrown it in the neighbor's yard. R2 stated she had a history of PTSD from an abusive ex-partner, so having someone yell at her was very triggering to her.
R2 stated staff had been assessing her anxiety, intervening as needed, and trying to keep them separated as much as possible, such as having her smoke on the back patio instead of the front patio, which had been helpful. R2 stated R8 was admitted to the hospital last night after making comments related to self-harm, and she slept a lot better with R8 not in the room.
During an interview on 4/1/26 at 11:05 a.m., the director of nursing (DON) stated R8's behaviors had been getting a lot worse over the last couple of days before her hospitalization last night.
The DON stated R2 had told her on Monday (3/30/26) that R8's behaviors and statements toward her made her anxious.
The DON talked about multiple interventions that had been attempted to assure both R2 and R8's safety, but when asked about reporting the incident to the SA, the DON stated she had not.
The DON stated the verbal altercations between R2 and R8 had not been reported, as she was unaware that she had to report incidents of resident-to-resident verbal abuse and thought it was just for physical or sexual abuse.The facility's Abuse Prevention Policy dated 5/30/25, indicated that allegations of abuse, serious bodily injury, or suspicion of a crime must be reported to the SA within two hours.
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every 12 months.
interview and document review, the facility failed to ensure complete and comprehensive Minimum
accuracy.Findings include:The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, identified the MDS as an assessment tool that facilities are required to use.
The manual directed comprehensive assessments, include the completion of both the MDS and the CAA process, as well as care planning.
The CMS RAI manual also identified that the RAI process (i.e., MDS) was completed to help evaluate residents' strengths and areas for care planning.R7's annual MDS dated [DATE], included the following information:-Section C- Cognitive Patterns: indicated C0100 (Should Brief Interview for Mental Status (C0200-C0500) be Conducted?) was not assessed, as well as Sections C0200 through C1310, fields regarding mental status, memory, cognitive skills, and signs of delirium.-Section D- Mood: indicated D0100 (Should Resident Mood Interview be Conducted?) was not assessed, as well as the entirety of Section D, an interview assessing the resident's mood/ a staff assessment of R7's mood.-Section F-Preferences for Customary Routine and Activities: indicated F-F0300 (Should Interview for Daily and Activity Preferences be Conducted?) was not assessed along with the entirety of section F, an interview for daily preferences/staff assessment of daily and activity preferences.-Section GG-Functional Abilities: indicated the entirety of the assessment was not assessed/dashed except one question, Does the resident use a wheelchair and/or scooter? which was coded as no.During an interview on 4/1/26 at 1:20 p.m., the infection control preventionist/ MDS coordinator (IC-MDS) stated that the facility had transitioned from using paper charts to using an electronic health record (EHR) at the beginning of the year.
The IC-MDS stated the facility did not have a good process in place for ensuring MDS assessments were completed and documented during this time.
The IC-MDS stated there was poor implementation and poor training of staff during the transition, so a lot of the MDS assessment areas had been missed during this period, such as R7's.The facility's MDS Completion and Submission Timeframe policy dated 3/2025, indicated the facility's assessment coordinator or designee was responsible for submitting the MDS assessment according to the RAI manual.
The policy did not further discuss the facility's process for MDS completion before submission.
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During an interview on 4/1/26 at 1:20 p.m., the infection control preventionist/ MDS coordinator (IC-MDS) stated that the facility had transitioned from using paper charts to using an electronic health record (EHR) at the beginning of the year.
The IC-MDS stated the facility did not have a good process in place for ensuring MDS assessments were completed and documented during this time.
The IC-MDS stated there was poor implementation and poor training of staff during the transition, so a lot of the MDS assessment areas had been missed during this period, such as R1's.
The facility's MDS Completion and Submission Timeframe policy dated 3/2025, indicated the facility's assessment coordinator or designee was responsible for submitting the MDS assessment according to the RAI manual.
The policy did not further discuss the facility's process for MDS completion before submission.
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accurately coded with the potential for inaccurate federal reimbursement and resident care planning
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.Findings include:R1's quarterly MDS dated [DATE], indicated under Section I: Active Diagnoses, that R1 did not have a diagnosis of non-Alzheimer's dementia.R1's Diagnosis Report dated 12/22/25, indicated R1 had a diagnosis of vascular dementia added on 12/22/25.R1's provider note dated 12/8/25, indicated R1 had a diagnosis of vascular dementia, and there had been some progression of this dementia.R3's quarterly MDS dated [DATE], indicated under Section N - Medications, that R40 had received 1 day of insulin injection(s) during the review period.R3's Medication Administration Record (MAR) dated 3/1/26 through 3/31/26, indicated R3 had received a single dose of Trulicity (a diabetes medication injection) during the lookback period (LBP); however, had not received any insulin during that time.
During an interview on 3/31/26 at 9:27 a.m., the director of nursing (DON) stated R1 did have a diagnosis of dementia and some related cognitive decline, and this year had been requiring more prompting from staff on things like personal care, but was still alert and oriented for things like making her own code status decisions.
During an interview on 4/1/26 at 1:20 p.m., the infection control preventionist/ MDS coordinator (IC-MDS) stated that she did not have a good understanding of Trulicity and mistakenly coded it as an insulin.
The IC-MDS stated she had not realized that R1 had a recent, active diagnosis of dementia, and it probably should have been added.The facility's MDS Completion and Submission Timeframe policy dated 3/2025, indicated the facility's assessment coordinator or designee was responsible for submitting the MDS assessment according to the RAI manual.
The policy did not further discuss the facility's process for MDS completion before submission.
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During interview with director of nursing (DON) on 4/1/26 at 8:44 a.m., DON stated expectations of
that may occur.
During interview with DON and the facility's MDS coordinator (IC)-MDS on 4/1/26 at 1:30 p.m., both reviewed R6's electronic medical record (EMR) and verified R6's quarterly care conference had not been done but should have been.
Both DON and IC-MDS verified R4's EMR lacked evidence of a care conference corresponding to the last MDS assessment.
Facility policy titled Care Conference, dated June 2018 identified All resident will have a care conference hosted a minimum of quarterly for each resident.
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During interview with administrator on 4/2/26 at 9:49 a.m., administrator stated facility did not have a
During interview with former activities director (FA)-A on 4/2/26 at 2:34 p.m., FA-A stated he resigned in October of 2025 after working as activities director since 2012. FA-A stated C-A was hired one week before FA-A resigned. FA-A stated he documented paper form of MDS assessment portion regarding Preferences for every resident when it was assigned to him by the MDS coordinator. A-A stated he did not complete progress notes, attendance records, or care plans. A-A stated there were never weekend activities.
During observations from 3/30/26 to 4/3/26 and 4/6/26 there were no activities performed or offered per activity calendar for March and April 2026, which was verified by DON and administrator.
During an interview on 4/6/26 at 1:28 p.m., the administrator stated that he was aware they had an issue with activities not being offered.
The administrator stated they had hired an activities aide (A)-A to try to solve this issue, but A-A ended up having to help out with doing activities such as facility shopping and running residents to appointments, so he did not have the time to lead activities for residents.
Facility Activity Calendars for October 2025 through April 2026 identified one column titled Weeks with five rows below it and five columns titled, Monday, Tuesday, Wednesday, Thursday, Friday.
Two activities were typed into each day.
The Activity Calendars did not have times and locations of activities.
Weekends were not included.
Facility assessment dated [DATE], identified Services and care offered based on Residents' Needs to include, Find out what residents' preferences and routines are and incorporate this information into the care planning process and Provide opportunities for social activities/life enrichment (individual, small group, community).
Facility policy titled Activity Evaluation with revision date of February 2023, identified, An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident.
Facility policy titled Activity Programs-Staffing with revision date of February 2023, identified, ensuring activity goals and approaches reflected in the residents' care plans are individualized to match the skills, abilities and interests/preferences of each resident.
Facility policy titled Activities Attendance with revision date of June 2018, identified, Attendance and participation is recorded for every resident in group and individual activities on a daily basis. and Attendance records are maintained and secured for a minimum of three years.
Also, Attendance records are used when completing residents' progress notes to determine their participation as it relates to their activity plan.
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andDeveloping, implementing, supervising and evaluating the activity programs at least quarterly.
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Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
Review of the facility timecards dated 10/1/25 to 12/31/25, indicated that on 11/5/25, 11/16/25, 11/20/25, and 12/21/25, the facility had no RN hours.
During an email communication on 3/31/26 at 4:21 p.m., the building owner (O)-O stated that on:11/5/25: An RN had been scheduled to work, but an LPN had to cover this shift.11/8/25: An RN was scheduled to work and did per timecard data.11/16/25: An RN called in, and an LPN ended up covering for her.11/20/25: An RN was scheduled for a shift, and an LPN ended up covering his shift.12/21/25: An RN was scheduled to work, and an LPN ended up covering the shift.
During an interview on 4/2/26 at 10:28 a.m., March 2026 timecard data was reviewed with the administrator, with no gaps in RN hours identified.
The administrator stated the facility used to have an issue with consistently filling RN hours, especially on the weekends, but they had been working to fix the issue, including using agency staff, and it had not been a problem recently.
The facility's Sufficient and Competent Nursing Staff policy dated 4/2025, indicated that the facility would staff an RN at a minimum of eight consecutive hours a day, seven days a week.
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minimal harm 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
an observation and record review on 4/1/26 at 8:08 a.m., the nurse staff posting was observed in a hallway between the dining room and the kitchen, attached to a bulletin board.
The posting had five columns, including days of the week, shift, registered nurse (RN) hours, licensed practical nurse (LPN) hours, and the date.
The posting did not include a daily census or the total number of licensed staff working every shift.
The posting showed the following information:-on Monday 3/29/26: 16 hours worked during the day shift, no hours recorded for the PM shift, and 8 hours recorded for LPN hours for the night shift.-on Tuesday, 3/30/26: eight RN hours for the day shift, eight LPN hours for the evening shift, eight LPN hours for the night shift.-on Wednesday, 3/31/26: no hours were recorded.-on Thursday, 4/1/26: no hours were recorded
During an interview on 4/1/26 at 1:10 p.m., the director of nursing (DON) stated she oversaw the staff posting.
The DON stated she usually waited until the end of the week, on Saturday, to fully fill out the staff posting as sometimes staff would call in and then the staff posting would not be accurate.
The DON stated that she was not aware that the census or the number of staff members needed to be on the staff posting so it had not been included.The facility's Posting Direct Care Daily Staffing Numbers policy dated 8/2022, indicated the nurse staffing information would be posted daily at the beginning of each shift and would include resident census and the total number of licensed nurses.
Based on observation, interview, and document review, the facility failed to ensure medications were
observed to have medications stored in an unsecured facility refrigerator.Findings include:During an observation and interview on 4/1/26 at 9:21 a.m. in the facility dining room, a medication cart with a small mini refrigerator next to it was observed.
The mini fridge was not observed to have a lock on it.
Registered nurse (RN)-A stated that they stored medications that needed refrigeration in the small mini refrigerator. RN-A was observed to open the mini fridge door and show that they have a small lock box inside, but they did not use it now. No medications were observed inside the lock box.
Inside the medication fridge, multiple boxes of medication were observed, including Copaxone (an injection medication used to treat multiple sclerosis), Ozempic (an injection medication used to treat diabetes), and Trulicity (an injection medication used to treat diabetes).
During an interview on 4/1/26 at 12:46 p.m., the director of nursing (DON) stated that about two to three months ago, she had moved the medications from a locked box in the main refrigerator where food was stored to this new mini refrigerator.
The DON stated she had not thought about the medication fridge needing a lock and confirmed the medication refrigerator did not currently have one.During email correspondence on 4/6/26 at 2:12 p.m., when asked for the names of the residents whose medications were kept in the small medication fridge, the administrator stated R1, R2, R3, R4, and R5.The facility's Medication, Labeling, and Storage policy dated 2/2023, indicated the facility would store all medications in a locked compartment, and only authorized personnel would have access to the keys.
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of 2 residents (R3, R4) reviewed for dental services.
Findings include: R3R3's face sheet identified R3
R3 with intact cognition, did not reject care, was independent with personal and oral hygiene, and diagnoses of schizoaffective disorder, bipolar, diabetes, anxiety, and epilepsy.R3's Care Area Assessment (CAA) dated 3/21/25 identified R3, Teeth show obvious cavities and missing most of upper teeth and triggered a dental care plan due to medications, unstable diabetes,R3's care plan (CP) dated 4/18/20, identified, PERSONAL HYGIENE/ORAL CARE: The resident requires supervision to assistance of 1 PRN to complete hygiene cares and The resident has potential for oral/dental health problems r/t Poor oral hygiene. In addition, CP intervention state, Coordinate arrangements for dental care, transportation as needed/as ordered.R3's electronic medical record (EMR) and paper chart failed to identify when R3 was offered and provided a routine dental appointment. R4R4's quarterly MDS dated [DATE] identified R4 with intact cognition, independent with all hygiene, and diagnoses of diabetes, post-traumatic stress disorder (PTSD), depression, and borderline personality disorder.R4's CAA dated 8/4/25, identified R4 as not being assessed for Dental Care-Care Planning Decision.R4's CP dated 10/28/25 state, Encourage resident to practice good general health practices: lose weight if overweight, stop smoking, compliance with dietary restrictions, compliance with treatment regimen, adequate sleep and exercise, good hygiene and oral care.During interview with R4 on 3/30/26 at 2:38 p.m., R4 stated she had been a resident at facility for two years coming up and had never been offered or provided a routine dental appointment. I should go at least every year.Review of R4's EMR and paper chart failed to identify documentation of R4 being offered and provided a routine dental appointment.During interview with administrator on 4/1/26 at 1:21 p.m., the administrator verified R3 did not have a dental visit scheduled or completed.
The administrator stated expectation of (DON) to keep [dental] appointments on [facility] appointment calendar.During interview with DON on 4/1/26 at 1:24 p.m., DON verified R3 and R4 EMR and paper charts failed to have documentation of routine dental appointments. DON stated dental appointments were necessary for all residents every 6-12 months. In addition, DON stated, I don't have a system to monitor and follow up on making sure the residents have had their dentist appointments and I do not have documentation that they refused or where they go for their appointments.Facility assessment dated [DATE], identified Services and care offered based on Residents' Needs with dental services.Facility policy titled Routine and Emergency Dental Services and Dentures, updated 01/28/2024 identifies, [facility] coordinates with each of the residents' dentist to ensure regular visits with a licensed dentist and, dental appointment will be scheduled for each resident a minimum of annually by a licensed dentist, where the resident's teeth will be evaluated for the condition of oral cavity, teeth and tooth-supporting structures, presence or absence of natural teeth or dentures, dentist or dental hygienist documents all resident exams for resident medical record which will include the name of licensed dentist, date of service, specific service provided, follow up orders or follow-up appointments, findings of dental status and oral health assessment, and the resident has the right to choose their dentist.
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daily cleaning and temp logs is important to ensure no illness occur from food.During observation and
interview with infection control preventionist (IC)-MDS on 4/1/26 at 1:09 p.m., IC-MDS stated
cooks are supposed to wear hair nets at all times.During observation and interview with CK-C on 4/3/26 at 10:43 a.m., CK-C stated he was the main cook for facility and that three cooks total were employed by facility. CK-C stated expectations of all three cooks to perform and document daily cleaning logs, and he was not aware of who was responsible for auditing and ensuring the logs were filled out. CK-C stated expectations of open food products to be dated and labeled, and stated he wasn't surprised the food in the fridge and spices were not dated or labeled.Facility Food Storage and Procurement Policy and Procedure, updated 03/30/2025, indicated opened bags of food must be labeled with the date the food was opened and staff would discard spoiled or contaminated food.
The policy directed staff to label food prepared at the facility with the name of the food, date the food was made, and use by date.
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During an interview on 4/6/26 at 1:28 p.m., the administrator stated that the facility held QAPI meetings monthly, but the QAPI committee was fairly new.
The administrator stated they did not currently have a formal process in place for collecting data to track and measure performance or a formal plan for QAPI at the moment.
The administrator confirmed the facility did not have any established goals or had any quality deficiencies that they had identified, such as issues with the activities program or the kitchen, that they were analyzing and developing corrective action plans for.
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During an interview on 4/6/26 at 1:28 p.m., the administrator stated that the facility held QAPI meetings monthly, but the QAPI committee was fairly new.
The administrator stated they did not currently have a formal process in place for collecting data to track and measure performance or a formal plan for QAPI at the moment.
The administrator confirmed the facility did not have any established goals or any quality deficiencies that they had identified, such as issues with the activities program or the kitchen, that they were analyzing and developing corrective action plans for.
The administrator stated the facility did not have a PIP in place currently and did not have a process in place to collect data for identifying high-risk, high-volume, or problem-prone areas or collecting information from residents or staff.
The facility's QAPI Program policy dated 2/2020, indicated the facility should develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for its residents.
The policy indicated the facility would develop a process for:-Tracking and measuring performance.-Establishing goals and thresholds for performance measurements.-Identifying and prioritizing quality deficiencies.-Systematically analyzing underlying causes of systematic quality deficiencies.-Developing and implementing corrective actions or performance improvement actions.-Monitoring/evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.The policy indicated the facility met monthly to review reports, evaluate data, monitor QAPI-related activities, and adjust the QAPI plan as needed.
Further documentation, such as a QAPI plan detailing the facility's developed process to meet the above requirements, was requested and not received.
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During an interview on 4/6/26 at 11:36 a.m., the infection preventionist (IC-MDS) stated she did not regularly attend QAPI meetings.
During an interview on 4/6/26 at 1:30 p.m., the administrator stated they had four staff members who regularly attended QAPI which included himself, the DON, the medical director, and the pharmacist.
The administrator stated he had tried to include the IC-MDS in the past, but it did not work with her schedule.
The administrator stated he was aware they needed additional staff members to attend QAPI meetings, but they had scheduling conflicts.
The facility's Quality Assurance and Performance Improvement (QAPI) Program- Governance and leadership policy dated 3/2020, indicated the facility would maintain a QAA committee which would meet at least quarterly, and the structure of the committee would consist of the administrator, the medical director, the DON, the infection preventionist, and members of pharmacy, social services, activity services, environmental services, human resources, and medical records as requested by the administrator.
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residents who resided in the facility.Findings include: During observation and interview with
clothes dryer located in basement of facility. HK-A stated she was responsible for all personal and facility laundry in addition to sweeping, dusting, vacuuming and washing hard surfaces. HK-A stated she was the facility's only housekeeper and worked 5 days per week. HK-A was observed walking downstairs to basement with soiled resident laundry in an uncovered plastic laundry basket that had holes/openings around it. HK-A stated she did not cover laundry when transporting it from resident rooms to the basement and when transporting clean linen to resident rooms and facility closets where linen and towels were located. HK-A verified she also did not wear personal protective equipment (PPE) gown when sorting and handling soiled and clean linen.During observation and interview on 3/31/26 at 7:35 a.m., HK-A walked to basement with both arms full of resident personal laundry. It was not covered. I do not cover laundry.During continuous observation on 4/1/26 from 7:10 a.m. to 7:27 a.m., R10 walked down the stairs to basement with both arms full of personal laundry.
The washing machine was running so she placed her laundry on top of the utility sink next to the washing machine and walked back upstairs.
The dryer had clean linen on it that was folded. It contained 3 blankets and a bed sheet.
Nothing was covered. HK-A walked downstairs and placed the clean linen that was on top of the dryer to an uncovered plastic laundry basket and walked upstairs past R10's soiled personal linen (which was sitting on top of the utility sink). HK-A walked back downstairs with the uncovered plastic laundry basket that contained soiled linen.
She placed contents of the washing machine into the dryer and then placed the soiled linen from laundry basket into the washing machine.
HK-A stated she had never washed or sanitized laundry baskets between soiled linen gathering and bringing clean linen back to residents and the facility unless the baskets were visibly dirty. HK-A verified she did not wear a PPE gown when sorting and handling soiled and clean laundry.During observation and interview with infection control preventionist (IC)-MDS on 4/1/26 at 1:09 p.m., IC-MDS stated expectation of housekeeping to cover linen when transporting and to clean the laundry baskets after each use to prevent contamination.Facility policy titled Housekeeping and Laundry reviewed 10/20/25 identified: -gown and gloves are available for workers to wear while sorting linens;-linen is covered during transport to prevent contamination while being moved through the facility;-soiled linen should be bagged or contained; and-Carry linen away from your body and uniform-Do NOT place soiled linen on furniture, floor, or other surfaces.
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Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
appropriateness of antibiotic including prophylactic antibiotic use to prevent antibiotic resistance and
facility who might use antibiotics.
Findings include:During entrance conference with administrator on 3/30/26 at 12:00 p.m., the administrator stated the infection control preventionist (IC)-MDS was responsible for the facility's infection control, surveillance, and antibiotic stewardship program.During interview with infection control preventionist (IC)-MDS on 4/1/26 at 12:48 p.m., IC-MDS stated she worked part time at facility since the fall of 2025 and visited facility once per week. IC-MDS stated she usually review the [resident] medication administration records (MARs) for antibiotics and anything that goes with it. In addition, IC-MDS stated, I am notified via email or when I arrive here weekly of signs and symptoms of potential illness. IC-MDS verified there is no communication to her regarding any residents being started on antibiotics prior to her weekly visits. IC-MDS stated she participated in an internal monthly meeting with DON [director of nursing], administrator, and our company operations manager that did not include the medical director. IC-MDS stated she had contact information for the medical director but had never attended meetings with the medical director, either in-person or on-line. IC-MDS stated, I just put the data in the binder (Infection and Antibiotic use Monthly Tracking form) and pharmacy and provider can look at the binder to see what is going on with new and ongoing signs and symptoms. IC-MDS stated she utilized a Monthly Tracking Sheets to monitor any resident infections or antibiotic use. IC-MDS verified June 2025, December2026, and January 2026 tracking forms were not filled in, indicating there were no infections identified during those months.Infection and Antibiotic use Monthly Tracking forms for the previous 12 months were reviewed and lacked multiple elements required in an antibiotic stewardship program, to include resident name, diagnostic testing and results, whether standardized criteria were used, resident symptoms, timeouts, and response to antibiotics.During interview with IC-MDS on 4/4/26 at 11:36 a.m., IC-MDS stated there was nothing written down for me to use as a guide for my part in the antibiotic stewardship program including antibiotic timeouts or reviews.
Also, IC-MDS stated she was not involved in any discussion on periodic review of prescribing practices because, the physician and pharmacist [can] look at that. IC-MDS stated she did not attend monthly QAPI meetings and could not speak to the facility's reports on antibiotic used, antibiotic resistance patterns, practices and facility assessment involvement.Facility policy titled Antibiotic Stewardship Program, dated 6/16/19 identified, information gathered will include at a minimum: Resident name Unit and room number Date symptoms appeared Name of antibiotic Start date of antibiotic Pathogen identified-if known Site of infection Date of culture; if applicable Stop date Total days of therapy Outcome Adverse events, if applicableThe Infection Preventionist and the Pharmacy Consultant will provide regular feedback on antibiotic use and outcomes to facility staff and the QAPI committee.
Feedback will also be provided to providers on their individual prescribing patterns of cultures ordered and antibiotics prescribed, as indicated.Education: Facility staff will be educated on the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community.Training and education will include the relationship between antibiotic use and: Gastrointestinal disorders Opportunistic infections (e.g., C. difficile, candida albicans, etc.) Development of drug-resistant organisms Medication interactionsResidents, families and clinicians will also be provided with resources to learn more about antibiotic stewardship.
Other educational opportunities identified thru the Antibiotic Stewardship Program will be provided as needed.
24E507 04/06/2026
Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
During interview with director of nursing (DON) on 3/31/26 at 11:38 a.m., DON stated the facility did not have a process in place to document vaccination status of all residents. DON stated the residents were all mobile and we send them to Walgreens and ask for a copy [of their vaccination information]. DON reviewed resident paper charts and electronic medical records (EMR) of all 13 residents and stated they lacked immunization records. ?[it is] hard to tell who needs a vaccine or not at this time. In addition, DON stated facility lacked documentation or messaging to providers to determine or ask about immunization status.Facility policy titled Pneumococcal, reviewed 10/20/25 identified: 1.
Upon admission to the facility (within 5 days), all residents will be assessed for current immunization status and eligibility to receive the pneumococcal vaccine, and within 30 days of admission, will be offered the vaccine, when indicated, unless the resident has already been vaccinated or the vaccine is medically contraindicated.2. If resident's immunization status is unknown, facility staff will contact resident's physician to determine record of immunization status from resident's permanent clinic record.3. If the vaccination is medically contraindicated, this will be documented in the resident's medical record.4.
Before receiving a pneumococcal vaccine, the resident or resident representative shall receive information and education regarding the benefits and possible side effects of the pneumococcal vaccine. (See current Vaccine Information Statements (VIS) on the CDC website for educational materials.) This education will be documented in the resident's medical record.5.
Pneumococcal vaccination will be administered at their own medical clinic, per physician and CDC recommendations, and will be documented in the resident's medical record.6.
Resident/resident's representative has the right to refuse vaccination. If refused, the date of the refusal will be documented in the medical record.7.
Documentation will include the date of the vaccination.Facility policy titled Influenza Outbreak Prevention and Treatment reviewed 10/20/25 identified: 3.
All residents will be interviewed upon admission and annually by the designated nurse to determine their current influenza season.5. If the vaccination is medically contraindicated, this will be documented in the resident's medical record.6. A resident's refusal of the vaccine (for reasons other than medical contraindication) will also be documented in the medical record.7.
Documentation in the medical record will include the date of the vaccination.
24E507 04/06/2026
Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
Based on interview and document review, the facility failed to establish and maintain documentation
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.Findings include: Residents:During interview with director of nursing (DON) on 3/31/26 at 11:38 a.m., DON stated the facility did not have a process in place to document vaccination status of all residents. DON stated the residents were all mobile and we send them to [pharmacy] and ask for a copy [of their vaccination information]. DON reviewed resident paper charts and electronic medical records (EMR) of all 13 residents and stated they lacked immunization records. ?[it is] hard to tell who needs a vaccine or not at this time. In addition, DON stated facility lacked documentation or messaging to providers to determine or ask about immunization status.Staff:Review of Centers for Disease Control and Prevention (CDC) Clinical Guidance for COVID-19 Vaccination, updated 10/31/24, directed the following guidance: People 5-64 years: should receive 1 dose of an age-appropriate 2024-2025 COVID-19 vaccine; People 65 years and older: should receive 2 doses of any 2024-2025 COVID-19 vaccine, spaced 6 months apart.During interview with CK-B on 3/31/26 at 8:27 a.m., CK-B stated he was hired as a cook for facility for almost one year. On 4/2/26 at 10:28 a.m., CK-A stated he had never been asked about his COVID-19 immunization status upon hire. CK-B stated facility never provided education on the benefits, risks, or side effects of the vaccine.During interview with director of nursing (DON) on 4/2/26 at 11:15 a.m., DON stated facility failed to have documentation of offering and providing education on the benefits, risks, or side effects of COVID-19 vaccine to CK-A and whether he declined.Facility policy titled Resident and Staff COVID-19, updated 07/25/2023, identified, All residents and staff members will be provided SARS-CoV-2 education and offered an opportunity to be immunized unless contraindicated or declined and documentation to be completed.
24E507 04/06/2026
Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
and the public.
good repair which had the potential to affect all 13 residents, staff, and visitors of the
must be ambulatory and not require a wheelchair. In addition, the Physical Environment-building needs portion of the FA identified, Outside grounds and building is maintained/repaired using the on-line maintenance work-order system.During entrance conference with administrator and director of nursing (DON) on 3/30/26 at 11:30 a.m., State Agency (SA) requested a list of residents who smoked.
At 3:13 p.m., an email was received from administrator which identified 6 of the 13 residents (R2, R3, R4, R5, R8, R9) as smokers.During observation and interview with R11 in his shared room on 3/30/26 at 1:07 p.m., R11 pointed to door jamb of his closet which had missing 3 inches of wood where the strike plate and the door latch met. R11 shrugged and said it had been there as long as he could remember and that it did not look well maintained. A window air conditioner unit resting on the window jamb had several gaps surrounding it where the outdoors was visible. R11 stated he was unable to use it because it trips the breaker. A small fan which was not operating had visibly soiled fins and was pointed towards R11. R11 stated it had never been wiped down or cleaned despite being used weekly.During observation on 3/30/26 at 12:00 p.m., the front of building on second floor facing the street had a large piece of window casing trim hanging in front of resident window.
The wood was hanging directly above smoking patio which encompassed the entire front of the building, with two residents sitting under it.During interview with director of nursing (DON) on 3/31/26 at 11:38 a.m., DON stated the residents were all mobile.During interview with administrator on 4/1/26 at 9:07 a.m., the administrator stated the facility did not have a system to document and follow up on resident concerns regarding environmental issues such as a water leaks, pest control, electrical issues, rooms too hot or cold, torn carpet, wall and window issues.
Administrator stated he would try to fix things himself or contract for services if he was unable to perform them.
Administrator stated facility did not have maintenance staff to monitor and audit environmental issues.During observation and interviews on 4/6/26 at 10:23 a.m., R4 and R9 were in their shared bedroom above the smoking patio with the hanging window casing trim.
The room had three windows facing the street.
All three windows had cracked, peeling, and missing paint along entire inside casing of windows. R4 stated one of the windows is so rotted it doesn't even stay open [when I open it]. R9 stated the hanging wood piece outside her bedroom window looks awful.
That piece is going to drop on someone and looks like it needs to be replaced. R4 stated she had complained about the inside window casing and the hanging piece of wood but nothing gets done. R4 stated she gave up hope they will fix it. R9 stated she thought the hanging piece of wood was unsafe for the people below it and worried that someone could get hurt if it disconnected from the frame of the house.During observation and interview on 4/6/26 at 10:51 a.m., with director of nursing (DON), DON looked at the hanging piece of wood at front of building overhanging the smoking patio. DON stated, that is so dangerous. DON also pointed out a large hole in the concrete patio sidewalk that connected the smoking patio to the side of the facility for wheelchair accessibility.
The hole measured 12 inches by 5 inches. DON stated, this is not safe and had not noticed it before and did not recall if she was informed of it by a resident, staff, or visitor.
DON then walked back into facility and walked upstairs to R4 and R9's shared room and observed the window ledges and inside jambs. DON verbalized that the condition of window jambs was rotted and needed to be replaced. DON stated she believed the condition of the windows were too far gone and I would hate that at my house.
Looks bad and is bad.Facility policy titled Grounds, revised May 2008 identified, areas around the buildings (i.e., sidewalks, patios, gardens, etc.) shall be maintained in a safe and orderly manner at all times.
24E507 04/06/2026
Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
Review of personnel records indicated that RN-B had not completed education that included resident rights in the last year.
During an interview on 4/6/26 at 11:40 a.m., when asked about abuse training, resident rights training, QAPI training, and infection control training, the director of nursing (DON) stated she would expect staff to complete training twice a year.
During an interview on 4/6/26 at 12:35 p.m., the human resources analyst (HRA) stated the facility did not usually have staff who continued employment past a year as RN-B had, so she had missed re-assigning her training for resident rights, abuse, and infection control, and confirmed the last time these were completed for RN-B was in 2024.
The facility's Sufficient and Competent Nursing Staff policy dated 4/2025, indicated that licensed staff would demonstrate the skills and techniques necessary to care for resident needs, including resident rights.
24E507 04/06/2026
Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
Review of personnel records indicated that RN-B had not completed education that included abuse/vulnerable adult training in the last year.
During an interview on 4/6/26 at 11:40 a.m., when asked about abuse training, resident rights training, QAPI training, and infection control training, the director of nursing (DON) stated she would expect staff to complete training twice a year.
During an interview on 4/6/26 at 12:35 p.m., the human resources analyst (HRA) stated the facility did not usually have staff who continued employment past a year as RN-B had, so she had missed re-assigning her training for resident rights, abuse, and infection control, and confirmed the last time these were completed for RN-B was in 2024.
The facility's Abuse Prevention Policy dated 5/30/25, indicated staff would complete abuse training annually and upon hire.
24E507 04/06/2026
Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
Review of personnel records indicated that the DON, RN-A, RN-B, LPN-A, and LPN-B had not completed education that included QAPI in the last year before survey entrance.
During an interview on 4/6/26 at 11:40 a.m., when asked about abuse training, resident rights training, QAPI training, and infection control training, the director of nursing (DON) stated she would expect staff to complete training twice a year.
During an interview on 4/6/26 at 12:35 p.m., the human resources analyst (HRA) stated that at some point, training requirements had changed, and the QAPI training had not automatically been added.
The HRA stated she had added QAPI training during the survey when she had realized the requirements were not being met.
The facility's Sufficient and Competent Nursing Staff policy dated 4/2025, indicated that licensed staff would demonstrate the skills and techniques necessary to care for resident needs, but did not specify that QAPI training would be completed.
24E507 04/06/2026
Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
Review of personnel records indicated that RN-B had not completed education that included infection control in the last year.
During an interview on 4/6/26 at 11:40 a.m., when asked about abuse training, resident rights training, QAPI training, and infection control training, the director of nursing (DON) stated she would expect staff to complete training twice a year.
During an interview on 4/6/26 at 12:35 p.m., the human resources analyst (HRA) stated the facility did not usually have staff who continued employment past a year as RN-B had, so she had missed re-assigning her training for resident rights, abuse, and infection control, and confirmed the last time these were completed for RN-B was in 2024.
The facility's Sufficient and Competent Nursing Staff policy dated 4/2025, indicated that licensed staff would demonstrate the skills and techniques necessary to care for resident needs, including infection control.
24E507 04/06/2026
Southside Care Center 2644 Aldrich Avenue South Minneapolis, MN 55408
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MINNEAPOLIS, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Southside Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.