Greater Southside Health and Rehab: Infection Control Failures - IA
The nurse, identified in the report as Staff D, an LPN, was observed on August 27 at 11:35 AM entering the room of Resident 9, a resident with quadriplegia whose care plan had directed staff since May 2025 to use enhanced barrier precautions whenever performing wound care or working with the resident's indwelling medical device. That order required a gown and gloves for high-contact care.
Staff D sanitized her hands and put on gloves. She cleansed the resident's left and right heels with gauze soaked in wound cleanser, then applied betadine, large absorbent dressings, and kerlix wrapping to each wound. She did not put on a gown at any point. She did not change her gloves or sanitize her hands when moving between steps, including between removing soiled dressings and applying clean ones.
The care plan for Resident 9 had flagged impaired skin integrity. The reason for the enhanced precaution order was specific: the risk of acquiring or spreading multi-drug resistant organisms, the category of bacteria that has become increasingly difficult to treat and that can colonize wounds and medical devices. The facility's own infection control policy, reviewed in August 2024, stated that protective equipment should be put on before entering the room and removed before leaving, with hand hygiene performed on the way out.
None of that happened.
Earlier the same morning, at 10:10 AM, Staff D had performed wound care on a second resident, Resident 11, whose right lateral foot wound had an order for daily cleansing, calcium alginate application, and a silicone dressing. Staff D removed the resident's foam boots, peeled back a dressing dated three days earlier, and assisted a nurse practitioner who debrided wounds on the right foot and left inner ankle. Staff D then cleansed the areas and applied the ordered dressings. Again, no gown.
The Director of Nursing told inspectors the next day that he expected staff to wear a gown and gloves any time they cared for a resident with a wound or a catheter. He said he also expected gloves to be changed between removing a dressing and applying a clean one, with hand hygiene in between. A certified nursing assistant interviewed the same day described the same expectation: gown and gloves for wound care, catheter care, or any resident with an infection.
The expectation was clear. The execution, on at least two residents in the same morning, was not.
What inspectors documented was not a lapse in knowledge. Staff D demonstrated she understood the basics: she sanitized her hands before starting, she put on gloves. The gown never appeared. The glove change between dirty and clean tasks never happened. The hand sanitizing between steps never happened. The gap was not between what staff knew and what the policy said. It was between what staff knew and what staff did.
For Resident 9, the stakes of that gap are not abstract. Quadriplegia limits a person's ability to fight infection, to reposition, to communicate early symptoms of a wound complication. The enhanced barrier precaution order existed because the risk of transmitting a drug-resistant organism to this resident, through contaminated hands or unprotected clothing, was considered high enough to require extra steps every single time. On August 27, those steps were skipped.
The inspection was conducted as a complaint investigation. Inspectors cited the deficiency at a level of minimal harm, though they noted potential for actual harm. The facility serves residents whose wounds and medical devices place them among the most vulnerable to infection. On the morning inspectors observed, the nurse performing their care was not wearing a gown.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Greater Southside Health and Rehabilitation in Des Moines, IA was cited for violations during a health inspection on September 3, 2025.
That order required a gown and gloves for high-contact care.
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.