Greater Southside Health: Wound Care Failures - IA
Federal inspectors found Greater Southside Health and Rehabilitation failed to follow treatment orders for Resident #11, who suffered from a Stage 3 pressure ulcer on her left ankle, a Stage 1 pressure ulcer, and one unstageable pressure ulcer. The facility houses 70 residents.
The resident's care plan, revised in May, documented impaired skin integrity related to wounds on her left inner ankle and coccyx, along with a history of infections. Staff were directed to administer treatments as ordered by physicians.
But the care plan contained a glaring omission. It lacked any information about a wound to the resident's right foot.
On August 21, a physician ordered daily wound care for the right lateral foot wound. The treatment required cleansing with a cleanser of choice, applying calcium alginate to the wound bed, and covering it with a silicone absorbent dressing daily and as needed.
Treatment records revealed the facility's failure to comply. Between August 1 and August 31, wound treatment and dressing changes to the right lateral foot were documented on day and night shifts only from August 24 through August 26.
Three days passed without the ordered daily care.
During an inspection observation on August 27 at 10:10 AM, inspectors watched Staff D, a Licensed Practical Nurse, and Staff E, a Wound Nurse Practitioner, finally tend to Resident #11. The resident lay in bed as Staff D removed foam boots from her feet.
A dressing covered the right lateral foot wound. The date on it read August 24 - three days old.
Staff D peeled away the outdated dressing. Staff E took a scalpel and debrided wounds on both the right lateral foot and left inner ankle. After Staff D cleansed the wound areas, she applied calcium alginate and a fresh silicone foam dressing.
Only then did Staff D place new tape labeled with that day's date, August 27, and her initials.
The Director of Nursing explained the facility's labeling system during an interview the following day. He expected staff to date and initial dressings whenever they changed them. For treatments ordered more than once daily, the dressing should be labeled with the date and staff initials.
"I would be able to tell who completed the dressing change and when the dressing was changed by checking the date and the staff's initials on the dressing," the Director of Nursing said.
The three-day gap between the August 24 dressing and the August 27 change violated the physician's daily treatment order. During those 72 hours, the resident's infected wounds remained covered by the same deteriorating dressing.
Federal regulations require nursing homes to provide treatment and care according to physician orders and residents' care plans. The facility's own policy, reviewed in August 2024, stated it would accurately implement orders and treatment orders in accordance with residents' plans of care.
The inspection documented how Greater Southside Health and Rehabilitation's staff failed to meet these basic standards. While the facility maintained detailed policies about following physician orders, the reality for Resident #11 was days of missed wound care.
The resident's medical history made consistent wound care critical. Her assessment revealed multiple pressure ulcers in various stages, from the Stage 1 ulcer requiring monitoring to the Stage 3 ankle wound representing significant tissue damage. The unstageable ulcer indicated wound severity that prevented inspectors from determining the full extent of tissue damage.
Pressure ulcers develop when sustained pressure reduces blood flow to skin and underlying tissue. Stage 3 ulcers involve full-thickness skin loss extending into subcutaneous tissue. Without proper daily care, these wounds can become infected, worsen, or fail to heal.
The inspection found that while nursing staff eventually performed wound care when observed by federal inspectors, the facility's treatment records revealed a pattern of missed care. The gap between August 26 and August 27 represented just the most recent failure to follow physician orders.
Resident #11's experience illustrated how policy compliance can break down at the bedside level, where residents depend on nursing staff to follow through on ordered treatments. The facility's 70 residents rely on staff to provide consistent, physician-ordered care.
The August inspection occurred after a complaint prompted federal review of the facility's practices. Inspectors classified the violation as causing minimal harm or potential for actual harm, though the resident's multiple infected pressure ulcers and history of infections suggested vulnerability to complications from delayed wound care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greater Southside Health and Rehabilitation from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Greater Southside Health and Rehabilitation in Des Moines, IA was cited for violations during a health inspection on September 3, 2025.
The facility houses 70 residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.