Greater Southside Health and Rehab: Abuse Reporting Failure - IA
The incident happened on October 10, 2025, at Greater Southside Health and Rehabilitation, a nursing facility at 5608 SW 9th Street in Des Moines. Federal inspectors documented the events during a complaint inspection completed October 27, and what they found was a screaming match between a licensed practical nurse and a cognitively intact resident who needed pain medication, witnessed by at least two other staff members, neither of whom reported it up the chain until the resident himself made a phone call.
The resident, identified in inspection records as Resident 3, had been admitted from a hospital. A mental status assessment scored him 13 out of 15, a range the instrument classifies as cognitively intact. He knew what was happening to him. He knew what he needed. And on the afternoon of October 10, he wasn't getting it.
A certified medication aide, identified as Staff C, told inspectors that a therapy staff member had come to ask whether Resident 3 could have his pain medication. Staff C said yes and would get there when finished with the current task. The therapy staff member came back a second time: Resident 3 was upset. Staff C then summoned LPN Staff A.
What happened next was documented in a statement from a second certified medication aide, Staff B, who was present in the hallway. Staff B heard Staff A and Resident 3 yelling at each other. Resident 3 said Staff A didn't control his medications. Staff A said she followed the doctor's orders, so yes, she did. Then, as Staff A left the room, Staff B heard her say it: the way Resident 3 was acting, he was not getting "his fucking oxy."
Staff C, who had summoned Staff A and was waiting outside the room, told inspectors there was much yelling back and forth, that Staff A said "do not give him shit," and that there was much cussing in both directions. Staff C walked away.
Nobody reported it that day. Nobody reported it the next day. Nobody reported it the day after that.
LPN Staff A, interviewed by inspectors on October 21, confirmed she had raised her voice. She said Resident 3 had been yelling profanities, and she got tired of it. "I just walked out," she told inspectors. She did not dispute that a confrontation had occurred.
The Administrator didn't learn about any of it until October 13, three days later, when Resident 3 called her himself. He alleged that Staff A had withheld his medication and used profanities toward him. The facility's own self-report, a five-day summary document, confirmed the Administrator received that call and that an investigation followed. The investigation's conclusion: Resident 3 had experienced "poor services." The corrective action: staff were educated on reporting abuse.
When inspectors interviewed the Administrator on October 27, she was direct about what should have happened. She said she would have expected staff to inform her directly, right away, about the verbal altercation and the resident's allegations on October 10. Instead, she heard about it from the resident three days later. She told inspectors she understood the obligation to report allegations of abuse in a timely way.
The Director of Nursing, interviewed October 23, confirmed that allegations of abuse needed to be reported to DIAL, Iowa's Department of Inspections, Appeals and Licensing. The regulation is specific: results of all investigations must be reported within five working days of the incident to the Administrator and the state survey agency. The facility didn't meet that standard, and the breakdown wasn't bureaucratic. Two people who witnessed the confrontation between Staff A and Resident 3 walked away from it and said nothing.
The deficiency was cited at a level of harm described as minimal harm or potential for actual harm. Federal inspectors noted the violation affected a small number of residents.
What the inspection report doesn't resolve is the underlying question Resident 3 raised when he finally got through to someone: whether he actually received his pain medication that afternoon, and whether the nurse's statement about not giving him "his fucking oxy" reflected something that had already happened or something she intended to carry out. The investigation's finding of "poor services" rather than confirmed abuse suggests the facility drew a line somewhere, but the report does not document where, or on what basis.
The care plan, notably, was absent. Inspectors noted that Resident 3's electronic file lacked care plan documentation entirely.
Staff B's statement, describing what was said in the hallway as Staff A left the room, was not dated. Staff C's statement was dated October 15, five days after the incident. By then, the Administrator had already heard the story from the resident himself.
The sequence matters: a resident in pain, asking for medication he'd been prescribed, ended up yelling in his room with a nurse. Two staff members heard enough to be troubled. One walked away from the door. The other caught the parting comment in the hallway and put it in a statement two weeks later. The resident, scored as fully cognitively intact, picked up a phone and reported himself.
Greater Southside Health and Rehabilitation's plan of correction for the deficiency is not contained in the inspection report. Inspectors noted that anyone seeking information about the facility's corrective plan should contact the nursing home or the state survey agency directly.
Resident 3 is still there, as far as the public record shows. The inspection report does not say otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greater Southside Health and Rehabilitation from 2025-10-27 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 24, 2026 · Our methodology
Greater Southside Health and Rehabilitation in Des Moines, IA was cited for abuse-related violations during a health inspection on October 27, 2025.
The incident happened on October 10, 2025, at Greater Southside Health and Rehabilitation, a nursing facility at 5608 SW 9th Street in Des Moines.
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.