Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southside Care Center during CMS and state inspections, most recent first.
The facility failed to employ a registered dietician, affecting all 11 residents receiving food. Interviews revealed inconsistencies in menu adherence and a lack of dietician involvement. The facility was between dieticians, with nursing staff completing nutritional assessments in the absence of a registered dietician. The facility policy allowed for dietary orders to be delegated to a qualified dietitian under physician supervision, but this was not being followed.
The facility failed to ensure proper sanitization of dishware and appropriate food storage, affecting all residents. The dish machine's temperatures fluctuated and did not consistently meet required levels, and food items were found undated and improperly stored. Staff did not consistently follow infection control techniques, such as hand hygiene between tasks.
The facility administration failed to provide adequate oversight and staffing, affecting resident care. The RN-A, acting as both DON and administrator, was overwhelmed due to the lack of an ADON replacement. The facility also lacked a registered dietitian and had issues with infection prevention training, MDS assessments, and PASARR processes. The QAPI and QAA processes were informal, with acknowledged room for improvement.
The facility failed to submit accurate staffing data to CMS for Q4 2024, with discrepancies between reported and actual nursing coverage. The DON admitted to reporting lower numbers due to payroll system limitations, despite having 24-hour coverage on the dates in question.
The facility failed to implement an effective QAPI plan, lacking formal processes for identifying and addressing quality deficiencies. The QAA committee meetings were not attended by the medical director, and the DON also served as the administrator, impacting the program's effectiveness. Meeting minutes focused on resident activities but did not address critical issues like falls. Staff interviews revealed reliance on informal feedback without structured evaluation mechanisms. The facility owner acknowledged the need for improvement in the QAPI process.
The facility's QAPI committee failed to effectively implement action plans to correct quality deficiencies, including MDS assessment inaccuracies, unmet resident activity needs, lack of trauma-informed care, and food sanitation issues. Meeting minutes lacked documentation on performance indicators and tracking of adverse events. Staff interviews revealed informal processes for addressing deficiencies, and the facility's owner acknowledged the need for improvement in the QAPI process.
The QA committee at the facility did not have all required members attending quarterly meetings, as the medical director was absent. Additionally, the facility lacked a trained infection preventionist after the previous one retired, and no staff were enrolled in specialized training. The facility's owner recognized the need for improvement in QAPI processes.
The facility failed to maintain proper infection control during laundry services, affecting all 11 residents. The head of housekeeping and laundry services used the same gloves to handle soiled and clean laundry without wearing a gown, contrary to facility policy. The RN expected staff to change gloves and perform hand hygiene before handling clean laundry.
The facility failed to ensure the acting infection preventionist (IP), the DON, had completed specialized training in infection prevention and control. The DON confirmed the lack of training, and no other staff were enrolled in such training. This deficiency had the potential to affect all 11 residents in the facility.
The facility failed to accurately code the MDS for several residents, leading to deficiencies in care assessments. One resident's activity preferences were inaccurately reported, while another's PASARR status was incorrectly coded, resulting in a lack of necessary mental health services. Staff interviews revealed a lack of understanding of the PASARR process and the importance of accurate MDS assessments.
The facility failed to complete Level II PASARRs for four residents with mental illness diagnoses before admission, as required. The director of nursing and staff were unaware of the process, leading to incomplete assessments and unmet mental health care needs.
The facility failed to serve food according to a menu and did not review changes with a dietician, affecting five residents with specific dietary needs. A resident with diabetes was non-compliant with their diet, while another with cardiac issues was not on a therapeutic diet. Staff interviews revealed inconsistencies in dietary practices, with the head cook admitting the menu was not always followed. The facility was between dieticians, leading to a lack of professional oversight in dietary management.
A facility failed to complete a comprehensive assessment for a resident, R7, using the RAI process, omitting her PTSD diagnosis despite documented trauma history. The MDS and care plan lacked documentation of her trauma and PRN antipsychotic use. Staff interviews revealed a lack of adherence to RAI guidelines, impacting R7's trauma-informed care.
A facility failed to incorporate PASARR level II recommendations into a resident's care plan. The resident, with a history of schizophrenia and other conditions, reported hallucinations and delusions, but her care plan lacked documentation of recommended services. Staff interviews revealed a lack of understanding of the PASARR process, and the facility could not provide relevant policies when requested.
A facility failed to review and revise a resident's activities care plan with input from the resident or their representative. The resident, with mild cognitive impairment, had preferences for activities like word find puzzles and music, but these were not documented in the care plan. Staff interviews revealed a lack of understanding and training regarding the activities care plan, and the facility's policy to incorporate resident preferences was not followed.
A resident with a history of depression, alcohol dependence, and cancer was discharged from an LTC facility without a proper discharge plan, leading to uncertainty about whether their medical and mental health needs could be met at the new location. The facility failed to document the discharge process adequately, and the resident was taken to a facility that had closed, with no communication established with the receiving facility.
A resident with mild cognitive impairment and mental health diagnoses was not provided with individualized activities, despite preferences for arts and crafts and group settings. The facility's care plan lacked documentation of specific activity preferences, and staff did not solicit input from the resident. Observations showed a lack of consistent arts and crafts offerings, and interviews revealed gaps in assessing and documenting activity preferences.
A facility failed to properly monitor a resident's blood pressure before administering Midodrine, a medication with specific hold parameters. The resident, with a history of orthostatic hypotension, was given the medication without a prior blood pressure check, contrary to the prescribed order. Interviews revealed inconsistencies in monitoring practices, and the need for clarification on medication orders was acknowledged by the DON.
A facility failed to identify and document triggers for a resident with a history of trauma, leading to a lack of a comprehensive trauma-informed care plan. The resident's care plan focused on behavioral triggers unrelated to her trauma history, despite staff awareness of her past trauma. The facility's policy on trauma-informed care was not followed, resulting in inadequate documentation and integration of the resident's trauma history into her care plan.
A facility failed to ensure a PRN psychotropic medication order for a resident included an end date or documented clinical rationale. The resident, with diagnoses of depression and alcohol dependence, received frequent PRN olanzapine without an end date or rationale for extending beyond 14 days. Interviews with staff highlighted the importance of adhering to the 14-day limit for such medications. The nurse practitioner confirmed the absence of an end date and stated no request for a rationale was received, although they believed the dose was appropriate.
The facility failed to accurately post nurse staffing information, omitting actual hours worked by RNs and LPNs. Discrepancies were found between posted staffing data and actual hours worked, confirmed by the DON. This affected all residents or visitors reviewing the information.
The facility failed to provide individualized non-pharmacological interventions for two residents with mental health disorders, leading to self-harm and hospitalizations. One resident, with a history of anxiety and self-injurious behavior, repeatedly used hot towels to self-soothe, resulting in burns. The care plan lacked specific interventions, and staff did not consistently offer PRN medications or alternative coping strategies. Another resident with schizoaffective disorder also lacked individualized behavior interventions. The facility lacked a policy for mental health management, contributing to these deficiencies.
Facility Lacks Registered Dietician, Affecting Nutritional Services
Penalty
Summary
The facility failed to employ a registered dietician or other qualified clinical nutrition professional to carry out the functions of a facility registered dietician, potentially affecting all 11 residents receiving food from the kitchen. Interviews revealed that the head cook, C-B, noted inconsistencies in menu adherence, with eggs not being served daily as planned, and other cooks not following the menu, complicating food ordering and usage. C-B also mentioned a lack of involvement from the registered dietician, who they believed had quit. The facility administrator and director of nursing, RN-A, acknowledged the absence of a dietician, stating that the newly hired dietician was not as involved as the previous one and that they were in the process of contracting a new dietician. Further interviews indicated that the facility was between dieticians, as the previous dietician had retired or resigned, with the last day being 5/31/24. RN-A confirmed that nursing staff completed nutritional assessments in the absence of a registered dietician, and C-B made menu changes as needed. The facility policy allowed for dietary orders to be delegated to a qualified dietitian under physician supervision, but this was not being followed due to the lack of a dietician. The certified physician assistant, CPA-B, stated they were not involved in nutritional assessments or diet orders, highlighting the gap in professional oversight in the facility's food and nutrition services.
Deficiencies in Dishware Sanitization and Food Storage
Penalty
Summary
The facility failed to ensure proper sanitization of dishware and appropriate food storage, affecting all 11 residents. During an initial tour, the head cook was observed not performing hand hygiene after removing gloves and handling dishes. The dish machine's wash and rinse temperatures fluctuated and did not consistently meet the required temperatures for proper sanitization. Additionally, the dish machine had mechanical issues, such as a door that did not close completely and a side panel that was not secured. Food storage practices were also inadequate. Items in the kitchen refrigerator, such as orange juice and milk, were undated, and a cup of juice was uncovered and unlabeled. The kitchen freezer contained opened and unlabeled tater tots and fish. In the dry storage area, cereal bags were not properly secured. The downstairs storage area had unlabeled chicken and cauliflower with white flaky crusts, indicating spoilage. A head of lettuce in the refrigerator was discolored and should not have been used. Staff did not consistently follow infection control techniques. A resident's personal water bottle was placed in the dish machine, which did not reach the required wash temperature. Staff were observed not washing hands between handling dirty and clean dishes. The facility's policies required labeling of opened food items and proper hand hygiene, which were not adhered to, contributing to the deficiencies observed.
Inadequate Oversight and Staffing Issues in Facility Administration
Penalty
Summary
The administration of the facility failed to provide adequate oversight, training, and guidance for appropriate resident care, which affected various aspects of the facility's operations. The facility did not have a replacement for the assistant director of nursing (ADON) after their retirement, leaving the registered nurse (RN)-A, who also served as the director of nursing (DON) and administrator, overwhelmed with responsibilities. This lack of staffing support hindered RN-A's ability to effectively manage both nursing and administrative duties, including the training of new staff and the handling of new admissions. The facility also failed to employ a registered dietitian or qualified clinical nutrition professional, as the hired dietitian believed the role could be performed virtually, which was not feasible due to technology issues. Additionally, RN-A was acting as the infection preventionist without specialized training in infection prevention and control, a fact that the facility's owner was unaware of. The facility's policy required relevant staff to be trained in infection control, but this was not adequately implemented. Furthermore, the facility had issues with the Minimum Data Set (MDS) assessments, as RN-B, who was responsible for these assessments, was new to the role and received insufficient training from RN-A. The facility also had deficiencies in the Pre-Admission Screening and Resident Review (PASARR) process, as some residents were admitted without completed assessments. The Quality Assurance and Performance Improvement (QAPI) and Quality Assurance and Assessment (QAA) processes were not formalized, and the facility's owner acknowledged the need for improvement in communication and time allocation for RN-A's dual roles.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter of 2024. The review of the facility's payroll-based journal (PBJ) staffing data report revealed that the facility did not have licensed nursing coverage 24 hours a day on multiple dates throughout the quarter. However, the facility's schedules indicated that there was indeed licensed nursing coverage for those dates, suggesting discrepancies between the reported data and the actual staffing levels. During an interview, the Director of Nursing (DON), who was also the administrator, acknowledged responsibility for submitting the PBJ data and admitted that the reported data were sometimes lower than actual staffing levels. This was attributed to the inability to report staff who had been discharged from the payroll system. The DON verified that there was licensed nursing coverage for the dates in question and stated that any inaccuracies in the reported data were unintentional. A policy regarding the reporting of PBJ data was requested but not provided.
Deficient QAPI Implementation and Oversight
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, which is essential for maintaining acceptable levels of performance and ensuring continual improvement in care and services. The facility's policy required a Quality Assessment and Assurance (QAA) committee to meet quarterly, consisting of key personnel such as the administrator, medical director, director of nursing (DON), program director, and consulting pharmacist. However, the medical director did not attend any of the QAA meetings, as evidenced by the absence of their signature on the meeting sign-in sheets. Additionally, the director of nursing was also serving as the administrator, which may have impacted the effectiveness of the QAPI program. The facility's QAA meetings lacked formal processes for identifying and addressing quality deficiencies, and there was no evidence of systematic data collection or analysis to identify high-risk or problem-prone areas. The facility's QAA meeting minutes revealed a focus on a quality improvement project aimed at enhancing resident activities and participation, but there was no mention of addressing falls or falls with injury, which are critical issues in long-term care settings. Interviews with staff indicated that the QAA process relied heavily on informal feedback and lacked structured mechanisms for evaluating health outcomes and resident safety. The facility owner acknowledged the need for improvement in the QAPI process and expressed reliance on the DON/administrator for updates on survey results and plans of correction. Overall, the facility's failure to implement a robust QAPI plan and ensure governing body oversight had the potential to affect all residents in the facility.
Ineffective QAPI Committee and Quality Deficiencies
Penalty
Summary
The facility failed to ensure the effectiveness of its Quality Assessment and Assurance (QAA) and Quality Assurance Process Improvement (QAPI) committee in implementing appropriate action plans to correct quality deficiencies identified in previous surveys. These deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, activities not meeting the interests and needs of each resident, lack of trauma-informed care, food sanitation issues, and failure to implement a QAPI plan and maintain a QAPI committee with improvement projects. The report indicates that these deficiencies had the potential to affect all residents residing in the facility. The review of the Certification and Survey Provider Enhanced Reporting (CASPER) system report showed that the facility had several deficiencies with a survey exit date of 11/30/23, including repeat deficiencies from a previous survey dated 10/22. The QAPI meeting minutes from various dates in 2024 and 2025 lacked documentation on how the facility developed, monitored, and evaluated performance indicators for improvement activities. Additionally, the minutes did not document how the facility identified, reported, and tracked adverse events, high-risk, high-volume, and problem-prone concerns. Interviews with facility staff revealed that correcting quality deficiencies was not a formal process and was not always included in the meeting minutes. The facility's RN-A acknowledged that the QAA committee could improve in comparing itself to benchmarks and tracking improvement projects. The facility's owner confirmed the need for improvement in the QAPI process and relied on RN-A for updates about survey results and the facility's plan of correction. The facility's policy indicated that the QAA committee should meet quarterly to develop an ongoing quality assurance program and implement plans of action to correct identified quality deficiencies.
QA Committee Lacks Required Members and Infection Control Training
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to ensure that all required members attended the quarterly meetings, as mandated by the facility's Quality Assessment and Assurance (QAA) program policy. The policy specified that the committee should include the administrator, medical director, director of nursing (DON), program director, and consulting pharmacist. However, the review of the QA meeting sign-in sheets revealed that the medical director did not attend any of the meetings throughout the year. Additionally, the sign-in sheets showed that a registered nurse (RN)-A was identified as both the DON and administrator, indicating a potential overlap in roles. Further interviews and document reviews highlighted additional issues within the facility's QA processes. RN-A reported that the facility's infection preventionist had retired and that no staff member had completed or was enrolled in specialized training for infection prevention and control. Despite attempts to interview the medical director, no response was received. RN-A mentioned that the certified physician assistant (CPA)-B attended the meetings as a continuity person, and information from the meetings was relayed to the medical director's designee. The facility's owner acknowledged the need for improvement in the Quality Assurance and Performance Improvement (QAPI) processes.
Infection Control Deficiency in Laundry Services
Penalty
Summary
The facility failed to maintain proper infection control practices during laundry services, potentially affecting all 11 residents. During an observation, the head of housekeeping and laundry services, identified as HK-D, was seen wearing gloves but no gown while handling laundry detergent, Clorox Bleach, and soiled linens. HK-D placed linens and bed sheets from a bag on the floor into the washing machine and folded clean washcloths using the same gloves. HK-D stated that wearing a gown was unnecessary for loading dirty laundry. However, the facility's policy required gowns to be available and used while sorting linens to prevent cross-transmission and adhere to standard precautions. When interviewed, the RN who was also the administrator and director of nursing, expected staff to wear gloves when handling soiled laundry and to change gloves and perform hand hygiene before touching clean laundry. The RN acknowledged that staff should avoid contact between dirty laundry and their body or arms and suggested that staff could be more careful by wearing gowns when handling dirty laundry.
Inadequate Training for Acting Infection Preventionist
Penalty
Summary
The facility failed to ensure that the acting infection preventionist (IP) had completed specialized training in infection prevention and control, which is a requirement for the role. The Director of Nursing (DON), who was serving as the acting IP, confirmed during an interview that he had not completed any specialized training in infection prevention and control. Additionally, no other staff members were currently enrolled in or scheduled for any specialized infection control education. The facility's policy on infection prevention, revised in July 2024, outlines that relevant staff should be trained in infection control upon hire and periodically thereafter. However, the facility did not adhere to this policy, as evidenced by the lack of specialized training for the acting IP. This deficiency had the potential to affect all 11 residents residing in the facility, as the infection control program was not being overseen by a qualified individual.
Inaccurate MDS Coding and PASARR Process Deficiencies
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for several residents, leading to deficiencies in their care assessments. For one resident, the MDS inaccurately reported her activity preferences, despite her having mild cognitive impairment and being able to communicate her preferences. The registered nurse admitted to not interviewing the resident about her activity preferences and instead relied on staff interviews, which led to a gap in understanding and an incomplete care plan that did not address the resident's activity needs. Another resident's MDS was inaccurately coded regarding her Level II PASARR status. Despite having a history of mental illness and being referred for a Level II PASARR, the MDS indicated she was not considered to have a serious mental illness. The facility lacked documentation of the services recommended under the Level II PASARR evaluation, and the registered nurse admitted to not knowing what services should have been provided, indicating a lack of understanding of the PASARR process. Additional deficiencies were noted for other residents, including inaccurate coding of PASARR status and medication use. One resident's MDS did not reflect her use of antianxiety and anticonvulsant medications, and another resident's MDS failed to document her PRN use of antipsychotic medication. The facility also failed to complete required Level II PASARR assessments before admitting residents, leading to a lack of necessary mental health services. Interviews with facility staff revealed a lack of knowledge and understanding of the PASARR process and the importance of accurate MDS assessments for developing appropriate care plans.
Failure to Complete Level II PASARR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Level II Pre-Admission Screening and Resident Review (PASARR) was completed prior to admission for four out of five residents who required it for mental illness. Resident 7 was admitted without a completed Level II PASARR, despite the Minnesota Senior Linkage Line indicating it was necessary. The Hennepin County supervisor confirmed that the assessment was not completed due to a lack of documentation from the facility. The registered nurse responsible for the Minimum Data Set (MDS) was unaware of the PASARR requirements and relied on the director of nursing, who also lacked understanding of the process. Resident 9 was admitted with a primary diagnosis of bipolar disorder, and the preadmission screening indicated a Level II assessment was required. However, the director of nursing admitted that the PASARR process fell through the cracks after a nurse who previously handled it retired. The medical record for Resident 9 lacked evidence of a completed Level II assessment, indicating a failure to meet the resident's mental health care needs. Resident 10 was admitted with diagnoses of bipolar disorder and post-traumatic stress disorder, and the preadmission screening required a Level II assessment. The director of nursing mistakenly believed the process was completed, but no Level II assessment was found. Resident 11 was admitted with similar mental health diagnoses, and the PASARR process was initiated only after admission. The director of nursing acknowledged the importance of completing PASARRs prior to admission to determine necessary services, but the facility did not have a policy in place to ensure compliance.
Facility Fails to Follow Menu and Review Dietary Changes with Dietician
Penalty
Summary
The facility failed to serve food according to a menu and did not review changes to the menu with a qualified dietician or other qualified nutrition professional. The facility also did not ensure that the menu met the nutritional needs of residents with specific dietary requirements, such as a cardiac diet. This deficiency affected five residents who were reviewed for dietary recommendations. The head cook admitted that the menu was not always followed, and there was confusion about the involvement of a registered dietician, as the previous dietician had left, and a new one had not yet been fully integrated. Resident 1 had mild cognitive impairment and several diagnoses, including diabetes mellitus and hyperlipidemia, and was on a no concentrated sweets diet. However, the resident's behavior sheet indicated non-compliance with the diet. Resident 2, with intact cognition and diagnoses including atrial fibrillation and hypertension, was supposed to be on a cardiac, consistent carbohydrate diet, but the MDS did not indicate a therapeutic diet. Resident 3, with intact cognition and diagnoses including orthostatic hypotension and hyperlipidemia, was on a regular diet with increased sodium. Resident 5, with intact cognition and diagnoses including diabetes mellitus, was also on a no concentrated sweets diet. Resident 10, admitted with intact cognition and at risk for malnutrition, was on a regular diet. Interviews with staff revealed inconsistencies in dietary practices. The head cook stated that other cooks did not follow the menu, making it difficult to manage food ordering and usage. The facility administrator acknowledged the lack of a dietician's involvement and stated that the facility was between dieticians. The registered nurse confirmed that residents were not following their prescribed diets, and the facility was not adhering to the menu. The facility's policy indicated that dietary orders could be delegated to a qualified dietician, but this was not being practiced due to the absence of a dietician.
Deficiency in Comprehensive Assessment and Trauma-Informed Care
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed and implemented using the Resident Assessment Instrument (RAI) process for a resident identified as R7. Upon admission, R7's Minimum Data Set (MDS) did not include a diagnosis of post-traumatic stress disorder (PTSD), despite her history of trauma being documented in other assessments. The Care Area Assessments (CAAs) for R7 identified her use of psychotropic medications and non-pharmacologic interventions but lacked documentation of her PRN use of olanzapine and her history of trauma. Additionally, the CAAs did not indicate if referrals to other disciplines were warranted. R7's care plan, while addressing her depression and behavioral management, did not document her history of trauma or the use of PRN antipsychotic medication. Interviews with facility staff revealed a lack of awareness and adherence to the RAI utilization guidelines, which are crucial for determining a resident's functional status and guiding further assessments. The registered nurse responsible for completing R7's MDS expressed hesitancy in reporting a PTSD diagnosis due to its absence in the primary or secondary diagnosis list, despite being aware of R7's trauma history. The facility's failure to accurately capture and document R7's trauma history and related triggers in her care plan and MDS assessments led to a deficiency in providing trauma-informed care. Interviews with the resident and staff highlighted the absence of discussions regarding R7's triggers and past trauma, which are essential for her psychosocial well-being. The facility's policies on comprehensive care planning and MDS or RAI were requested but not provided, indicating potential gaps in procedural adherence and staff training.
Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program by not incorporating recommendations from the PASARR level II determination into the care plan for one resident. The resident, who had a history of schizophrenia, alcohol dependence in remission, insomnia, history of cocaine abuse, and encephalopathy, was not considered by the state to have a serious mental illness or intellectual disability according to her Minimum Data Set (MDS). However, she reported hallucinations and delusions during the lookback period. The Care Area Assessments (CAAs) triggered several areas of concern, but lacked documentation on whether referrals to other disciplines were warranted. The resident's care plan and behavioral management care plan did not include documentation of services recommended under her level II PASARR evaluation. Interviews with facility staff revealed a lack of understanding and awareness regarding the PASARR process. A registered nurse (RN-B) admitted to inaccurately coding the MDS and being unaware of what a PASARR was. The director of nursing (RN-A) also expressed uncertainty about the services recommended under the level II PASARR and admitted to not having read the PASARR evaluation. The facility was unable to provide a PASARR policy or a policy pertaining to MDS accuracy when requested. This lack of coordination and documentation indicates a deficiency in the facility's compliance with PASARR requirements.
Failure to Review and Revise Activities Care Plan
Penalty
Summary
The facility failed to review and revise the activities care plan with input from a resident and/or their representative. The resident, who was reviewed for activities, had a Brief Interview for Mental Status (BIMS) score indicating mild cognitive impairment and was able to communicate effectively. Despite this, the Minimum Data Set (MDS) reported that the interview for daily and activity preferences was not conducted because the resident was rarely/never understood, and no family or significant other was available. The resident's Care Area Assessment (CAA) indicated a preference for certain activities, such as word find puzzles and listening to music, but these preferences were not documented in the care plan. The care plan, revised on a specific date, identified the resident's risk for not meeting emotional, intellectual, physical, and social needs due to cognitive deficits and other conditions. However, it lacked documentation of the resident's activity preferences. Interviews with staff revealed that the registered nurse responsible for the MDS assessments did not interview the resident about activity preferences and acknowledged a gap in understanding regarding the activities care plan. The facility's director of nursing and administrator confirmed that the training provided to the registered nurse on the MDS process could have been more robust. The facility's policy directed staff to incorporate resident preferences into activities, but a comprehensive care plan policy was not provided.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to adequately plan and evaluate the discharge needs of a resident, leading to a discharge to an unknown location without ensuring the resident's medical, mental health, and medication needs could be met. The resident, who had a history of major depressive disorder, alcohol dependence, and cancer, was discharged to a location where it was unclear if their needs could be accommodated. The facility did not have an active discharge plan in place, and the resident did not want a referral to a local contact agency. The resident's care plan did not include discharge planning and indicated the need for pain management, assistance with scheduling medical appointments, and follow-up with oncology staff. Despite these needs, the resident was discharged with all medications, and staff dropped them off at an address that was later found to be a closed facility. The facility's registered nurse and director of nursing stated that the discharge was self-directed by the resident, who did not provide details about the social worker or the discharge location. Interviews with facility staff revealed that the discharge process was not properly documented, and there was no discharge summary available for the resident. The facility's registered nurse acknowledged that the discharge happened faster than desired and without the usual procedures, such as filling out a discharge summary and ensuring communication with the receiving facility. The resident's psychiatric office and chemical counselor were not informed of the discharge, and the facility did not have a policy related to discharge available for review.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities for a resident with mild cognitive impairment and multiple mental health diagnoses, including anxiety, bipolar disorder, schizophrenia, and mild intellectual disabilities. The resident's Minimum Data Set (MDS) indicated a preference for participating in favorite activities and group settings, yet the Care Area Assessment (CAA) noted a lack of interest in activities other than word find puzzles. The resident's care plan aimed to maintain involvement in cognitive and social activities but lacked documentation of specific activity preferences. Observations and interviews revealed that the resident expressed a desire for more arts and crafts activities, which were not consistently offered according to the activities participation logs and calendars. The resident reported that staff did not solicit input on activity preferences and mentioned a lack of supplies for crafts due to budget constraints. Despite the presence of various games and books in the facility, the resident noted the absence of a craft bucket and expressed interest in both structured group activities and independent options. Interviews with facility staff, including the Health Unit Coordinator (HUC) and Registered Nurse (RN), highlighted gaps in assessing and documenting the resident's activity preferences. The HUC confirmed that the resident enjoyed word puzzles and bingo but had not recently updated the resident's activity preferences. The RN acknowledged a lack of an activities care plan focus and expressed uncertainty about the MDS process. The resident's medical doctor emphasized the importance of activities in managing the resident's mental health, noting that engaging in activities could distract from psychosis and improve mood.
Failure in Blood Pressure Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure appropriate blood pressure monitoring and medication administration for a resident diagnosed with orthostatic hypotension, hyperlipidemia, depression, and schizophrenia. The resident was prescribed Midodrine HCL with specific instructions to hold the medication if blood pressure was 110 mmHg or higher, and to administer it if the resident exhibited symptoms of hypotension. However, during a medication administration observation, the registered nurse (RN) did not check the resident's blood pressure before giving the medication, which was against the prescribed order. The RN admitted to normally checking the blood pressure before and after medication administration to assess effectiveness, but failed to do so on this occasion. Further interviews revealed inconsistencies in the facility's practice regarding blood pressure monitoring. The licensed practical nurse (LPN) and certified physician assistant (CPA) both indicated that blood pressure should be checked before administering medication with hold parameters. The consultant pharmacist had previously recommended clarifying the frequency of blood pressure checks due to the twice-daily administration of Midodrine, but there was no evidence of follow-up on this recommendation. The director of nursing acknowledged the need to clarify the medication order and confirmed that the resident's blood pressure had not reached 110 mmHg or above, indicating a lack of adherence to the prescribed monitoring protocol.
Failure to Implement Trauma-Informed Care Plan
Penalty
Summary
The facility failed to identify and document triggers to avoid potential re-traumatization and did not develop a comprehensive care plan with individualized trauma-informed approaches for a resident with a history of trauma. The resident, who had intact cognition and no hallucinations or delusions, was diagnosed with depression and alcohol dependence but did not have a PTSD diagnosis on her Minimum Data Set (MDS). Her Care Area Assessments (CAAs) for psychosocial well-being and mood state identified the use of psychotropic medications and non-pharmacologic interventions but lacked documentation of triggers or referrals to other disciplines. A comprehensive trauma-informed care assessment identified specific triggers such as loud male voices and yelling, but these were not included in the resident's care plan. Instead, the care plan focused on behavioral triggers related to sleep apnea, insomnia, and stress from medical appointments, without addressing the resident's history of trauma. Interviews with facility staff revealed that while the resident's trauma history was known, it was not adequately documented or integrated into her care plan. The facility's policy on trauma-informed care required assessments upon admission and collaboration with residents and their support systems to develop individualized interventions. However, the policy was not followed, as evidenced by the lack of documentation and integration of the resident's trauma history and triggers into her care plan. Interviews with staff indicated a misunderstanding of the policy requirements and a failure to capture necessary information in the MDS within the required timeframe.
Failure to Document End Date or Rationale for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication order for a resident included an end date or a documented clinical rationale. The resident, who had intact cognition and no hallucinations or delusions, was diagnosed with depression and alcohol dependence. The resident's medication administration record showed frequent administration of PRN olanzapine without an end date or clinical rationale for extending the order beyond the 14-day limit. Interviews with the consultant pharmacist and certified physician assistant highlighted the importance of adhering to the 14-day limit for PRN psychotropic medications to ensure appropriate use and monitoring for adverse effects. The nurse practitioner responsible for the resident's psychotropic medication management confirmed the absence of an end date for the PRN olanzapine order and stated that no request for a clinical rationale to extend the order had been received. The nurse practitioner expressed a belief that the resident was on an appropriate dose of olanzapine and would have provided a clinical rationale if requested. The facility's failure to provide a policy on psychotropic drug use further contributed to the deficiency.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information accurately displayed the actual hours worked by licensed staff for each shift on a daily basis. This deficiency was identified through interviews and document reviews, which revealed discrepancies between the posted staffing information and the actual hours worked by registered nurses (RNs) and licensed practical nurses (LPNs). The weekly staffing posts for the periods from 1/1/25 to 1/28/25 included the facility's name, date, census, and total hours for RNs, LPNs, and trained medication assistants (TMAs), but lacked the actual worked hours for RNs and LPNs. Further investigation showed that the facility schedules for the periods from 1/1/25 to 1/31/25 indicated actual hours worked per shift that contradicted the total hours posted on the weekly staffing posts. During interviews, the director of nursing (DON), who was also the administrator, confirmed responsibility for the weekly staffing posts and acknowledged the discrepancies. Despite a request for a policy pertaining to staffing posts, no such policy was provided. This failure had the potential to affect all 11 residents or visitors who wished to review the staffing information.
Failure to Implement Individualized Behavioral Interventions
Penalty
Summary
The facility failed to develop and implement individualized non-pharmacological interventions to manage behaviors for two residents with mental health disorders. One resident, who had a history of anxiety and self-injurious behavior, was admitted with multiple mental health diagnoses, including borderline personality disorder and generalized anxiety disorder. Despite being cognitively intact and independent in mobility and activities of daily living, the resident experienced episodes of anxiety that led to self-harm using hot towels. The care plan lacked specific interventions to prevent such behaviors, and the facility did not consistently offer PRN medications or alternative coping strategies. The resident's care plan was not updated with individualized interventions to prevent self-harm, and there was no comprehensive assessment to determine triggers or behavior patterns. The facility's documentation revealed multiple instances where the resident attempted to use hot towels to self-soothe, resulting in burns and hospitalizations. Interviews with staff indicated a lack of awareness of non-pharmacological options and an over-reliance on PRN medications, which were not always offered proactively. The facility's administrator acknowledged the shortcomings in offering PRN medications and the lack of individualized care plans. Another resident with schizoaffective disorder also lacked individualized behavior interventions in their care plan. The facility did not have a policy or procedure related to mental health or behavioral management, which contributed to the deficiencies in care. Interviews with staff and family members highlighted the need for better management of anxiety and sleep disturbances, as well as the importance of offering PRN medications based on observed behaviors rather than waiting for resident requests.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Care Home | 0.6 mi | — | 3 | 0 |
| Redeemer Health Care Center | 0.6 mi | — | 0 | 0 |
| The Estates At Chateau Llc | 0.9 mi | — | 13 | 1 |
| Benedictine Health Center Of Minneapolis | 1.3 mi | — | 8 | 0 |
| Lakehouse Healthcare & Rehabilitation Center | 1.4 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.