Greater Southside Health and Rehab: Admission Failures - IA
The resident, identified in inspection records as Resident 3, was admitted between 3:00 and 4:00 PM. By 6:00 PM, they were asking for pain medication. By the next morning, they had missed their evening insulin dose, their morning insulin dose, and every blood sugar check in between. Nobody disputes this. A corporate registered nurse told inspectors the delay "caused R#3 unnecessary pain."
The admission paperwork had fallen into a gap that, apparently, everyone at the facility knew existed.
Staff K, the nurse working when Resident 3 arrived, told inspectors that when the job started, floor nurses were told they don't handle admission paperwork. Staff K wasn't sure which member of management was supposed to. Without a diet order in the system, Staff K looked at the diagnosis list and decided to hand over a regular room tray. The shift ended at 7:30 PM.
LPN Staff D took over at 6:00 PM and was told there was a new admit. When Resident 3 asked for pain medication, Staff D called the Director of Nursing for orders and was told that Corporate RN Staff G would be entering them into the system. Staff D told the resident the medications hadn't arrived from the pharmacy. That wasn't accurate. The oxycodone was already there. But without orders in the system, Staff D said, there was no authorization to give it.
Staff D called Staff G anyway. Staff G said to give the medications that had arrived from the pharmacy. Staff D didn't feel comfortable doing that without orders.
So Staff D called the on-call nurse practitioner, Staff J, who gave a verbal order for 10 milligrams of oxycodone because, as the record states, Resident 3 was in so much pain. Staff D also called the hospital to have the transfer orders faxed over. When the shift ended the next morning, the fax still hadn't come through. Staff D wasn't even sure the fax machine was working.
Staff G, the corporate RN who had agreed to enter the admission orders, told inspectors she received the orders by email from the Assistant Director of Nurses, but those orders didn't include medications. She couldn't add orders to the system from what she had. It wasn't until Staff D called around 11:00 PM that Staff G learned Resident 3 still had no orders and was in pain. That's when Staff G told Staff D to give the oxycodone and get the full orders from the hospital. When Staff G arrived at the facility the next morning, the hospital orders still hadn't been received.
Resident 3 is diabetic. Missing one insulin dose creates risk. Missing two consecutive doses, with no blood sugar monitoring in between, compounds it. The pharmacist, Staff F, told inspectors he would have expected a call from the facility if there were any concerns about medications. He also noted the facility had access to an emergency medication kit and a 24-hour pharmacy on-call line. Neither was used.
The inspection was conducted as a complaint investigation and completed October 27, 2025. Inspectors cited the deficiency under the federal tag covering comprehensive resident assessments, noting the level of harm as minimal or potential for actual harm.
The facility's own admission policy, last revised in July 2023, lists as its first directive: inform the physician of the admission and verify transfer and admission orders. It lists ordering medications from the pharmacy second. Resident 3 had been at the facility for roughly seven hours before anyone reached the nurse practitioner for a single verbal order, and nearly twenty-four hours passed before the full picture of what the resident needed was in the system.
A corporate nurse agreed the delay caused unnecessary pain. The insulin doses weren't recovered. They were simply gone.
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 violations during a health inspection on October 27, 2025.
The resident, identified in inspection records as Resident 3, was admitted between 3:00 and 4:00 PM.
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.