Southside Care Center

Inspection findings

1. Apr 6, 2026 Fire Safety · 28 findings
   • Not serious Scope/severity C

     E0025 Emergency Preparedness Deficiencies

     Create arrangements with other facilities to receive patients.

     Corrected May 29, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected May 29, 2026 · CMS health inspection

   • Serious Scope/severity J

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Mar 31, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0636 Resident Assessment and Care Planning Deficiencies

     Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0638 Resident Assessment and Care Planning Deficiencies

     Assure that each resident’s assessment is updated at least once every 3 months.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0680 Quality of Life and Care Deficiencies

     Ensure the activities program is directed by a qualified professional.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected May 29, 2026 · 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 May 29, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0791 Quality of Life and Care Deficiencies

     Provide or obtain dental services for each resident.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     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 Jun 20, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0865 Administration Deficiencies

     Have a plan that describes the process for conducting QAPI and QAA activities.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0887 Infection Control Deficiencies

     Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

     Corrected Jun 20, 2026 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected May 29, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0942 Resident Rights Deficiencies

     Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

     Corrected Jun 20, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0943 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

     Corrected Jun 20, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Jun 20, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0945 Infection Control Deficiencies

     Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

     Corrected Jun 20, 2026 · CMS health inspection

2. Feb 3, 2025 Health · 21 findings
   • Not serious Scope/severity D

     F0636 Resident Assessment and Care Planning Deficiencies

     Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0660 Resident Assessment and Care Planning Deficiencies

     Plan the resident's discharge to meet the resident's goals and needs.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Apr 4, 2025 · 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 Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0801 Nutrition and Dietary Deficiencies

     Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     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 Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0835 Administration Deficiencies

     Administer the facility in a manner that enables it to use its resources effectively and efficiently.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0865 Administration Deficiencies

     Have a plan that describes the process for conducting QAPI and QAA activities.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Apr 4, 2025 · CMS health inspection

3. Oct 23, 2024 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0740 Quality of Life and Care Deficiencies

     Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

     Corrected Nov 28, 2024 · CMS health inspection

4. Nov 30, 2023 Fire Safety · 14 findings
   • Not serious Scope/severity C

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Feb 9, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Feb 9, 2024 · 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 Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0791 Quality of Life and Care Deficiencies

     Provide or obtain dental services for each resident.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity F

     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 Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0865 Administration Deficiencies

     Have a plan that describes the process for conducting QAPI and QAA activities.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 9, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Feb 9, 2024 · CMS health inspection