Greater Southside Health And Rehabilitation

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview, and policy review the facility failed to ensure a resident's buttocks was appropriately covered in order to maintain the resident's dignity for one of sixteen residents sampled (Residents #15). The facility reported a census of 70 residents.Findings include:The Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #15 had diagnoses of severe intellectual disability and schizoaffective disorder. The MDS recorded the resident had a Brief Interview for Mental Status Score of 9, indicating moderately impaired cognition. The MDS indicated the resident required partial to moderate assistance for lower body dressing. The Care Plan revised 5/22/25 revealed

the resident required assistance with Activities of Daily Living (ADL's). The Care Plan directed staff to provide assistance of one for dressing. During observation on 8/25/25 at 12:04 PM, Resident #15 sat in a chair by a table in the upper dining room with her buttocks fully exposed. At the time, nine other residents were in the same dining room. One male resident sat at a table facing Resident #15's backside. At 12:08 PM, four staff were lined up by the kitchen waiting for food to be plated and in order to deliver plates of food to the residents in the upper dining room. Staff walked back and forth between the kitchen and the upper level dining hall, and walked past Resident #15. At 12:12 PM, Staff B, Certified Medication Aide, placed a blanket between Resident 15's back and the chair to cover the resident's exposed buttocks. In an interview 9/2/25 at 4:05 PM, the Administrator reported sometimes a resident would expose their body but he expected the staff to ensure the resident's backside was appropriately covered. A Dignity and Privacy policy revised 10/2024 revealed all residents treated with dignity and privacy. Residents will be appropriately dressed in a manner that maintains the privacy of their body.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greater Southside Health and Rehabilitation

5608 SW 9th Street Des Moines, IA 50315

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, clinical record review, staff interview, and policy review the facility failed to administer treatments and perform dressing changes as ordered by the physician for one of four residents reviewed (Resident #11). The facility reported a census of 70 residents.Findings include: The Significant change in status Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #11 had a Stage 3 pressure ulcer on the left ankle, one Stage 1 pressure ulcer and one unstageable pressure ulcer. The MDS recorded

the resident required application of nonsurgical dressings and medications for skin treatments. The Care Plan revised 5/23/25 revealed the resident had impaired skin integrity related to wounds on her left inner ankle and coccyx, and also had a history of infections. The care plan directed staff to administer treatments as ordered. The Care Plan lacked information about a wound to the right foot. The Order Summary Report dated 8/27/25 revealed an order to cleanse the right lateral foot wound with cleanser of choice, apply calcium alginate to the wound bed, cover the wound with a silicone absorbent dressing daily and as needed for wound care with order date of 8/21/25.The Treatment Administration Record dated 8/1/25 to 8/31/25 revealed a wound treatment and dressing change to the right lateral foot documented on the day and the night shift 8/24/25 to 8/26/25.During observation on 8/27/25 at 10:10 AM, Staff D, Licensed Practical Nurse (LPN) and Staff E, Wound Nurse Practitioner, were in the room with Resident #11. Staff D removed the foam boots on the resident's feet while the resident was lying in bed. A dressing was observed to the right lateral foot dated 8/24/25. Staff D removed the dressing over the right lateral foot. Staff E took a scalpel and debrided the wounds to the right lateral foot and left inner ankle. Staff D cleansed the wound areas and applied calcium alginate and a silicone foam dressing. Staff D then placed a piece of tape labeled 8/27 and her initials. In an interview 8/28/25 at 10:15 AM, the Director of Nursing (DON) reported he expected staff date and initial the dressing whenever a resident's dressing had been changed. The DON explained if a treatment or dressing change was ordered more than once a day, the dressing should be labeled with the date and the staff's initials. The DON reported he 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. A Physician's Order policy reviewed 8/2024 revealed the facility accurately implemented orders in addition to treatment orders in accordance with the resident's plan of care.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greater Southside Health and Rehabilitation

5608 SW 9th Street Des Moines, IA 50315

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

CNAs. She stated she knows the facility has been working on it, but it is still difficult and has led to not everything getting done. An interview on 09/02/2025 at 10:27 AM with Staff H, Licensed Practical Nurse (LPN), he stated that while staffing has gotten better, they can still improve.

An interview on 09/02/2025 at 10:32 Am with Staff A, CNA, she stated the facility still struggles with staffing. At least once a week they are so short staffed that it is difficult to get everything done.

A review of time card data from 07/28/2025, 08/04/2025, and 08/22/2025 failed to document the required number of CNAs on several shifts. It also documented the Director of Nursing (DON) worked the floor from 10pm-6am on 07/28/2025.

Review of Resident Council Notes dated 8/22/25 documented facility call light times were still out of parameters (greater than 15 minutes) and that beds were still not getting made. Review of the Facility Assessment from 2025, it documented there are to be at least 5 CNAs on day and evening shifts, and 4 or more on the overnight shift.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Greater Southside Health and Rehabilitation

5608 SW 9th Street Des Moines, IA 50315

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Barrier Precautions (EBP) during high resident contact care activities due to wounds.

Level of Harm - Minimal harm or potential for actual harm

The Order Summary Report dated 8/27/25 revealed an order to cleanse the right lateral foot wound with cleanser of choice, apply calcium alginate to the wound bed, cover the wound with a silicone super absorbent dressing daily and as needed for wound care.

Residents Affected - Few

During observation on 8/27/25 at 10:10 AM, Staff D, LPN, and Staff E, Nurse Practitioner, were in the room with Resident #11. Resident lying in bed. Staff D removed the foam boots on the resident's feet. A dressing was observed to the right lateral foot dated 8/24/25. Staff D removed the dressing over the right lateral foot.

Staff E took a scapel and debrided the wounds to the right lateral food and left inner ankle. Staff D cleansed

the wound areas and applied calcium alginate and a silicone foam dressing. Staff D placed a piece of table labeled 8/27 and initials KW. Staff did not wear a gown while performing treatment or the dressing change

on the resident's wound.

1. 3. The Quarterly MDS assessment dated [DATE REDACTED] revealed Resident #9 had diagnoses of quadriplegia. The

MDS recorded the resident had no skin conditions such as a pressure ulcer present.

The Care Plan revised 1/10/25 revealed the resident had impaired skin integrity. The Care Plan directed staff to provide treatments per the physician's orders and use enhanced barrier precautions.

The Order Summary Report dated 8/2025 revealed an order for EBP's with start date of 5/14/25. EBP's indicated due to wound and indwelling medical device. Use of a gown and gloves required for high contact care activities.

During observation on 8/27/25 at 11:35 AM, Staff D obtained supplies from a treatment cart, then took the supplies to Resident #9's room. Staff D sanitized her hands and donned a pair of gloves. Staff D took a gauze soaked in Vashe wound cleanser and cleansed the resident's left and right heels. Staff D applied betadine, an ABD (large) dressing, and kerlix to each wound. Staff D did not wear a gown during the procedure, and did not change gloves or sanitize hands when going from a dirty to clean task. In an

interview 8/28/25 at 11:30 AM, Staff A, Certified Nursing Assistant (CNA) reported EBP used whenever wound care or catheter care performed, or if a resident had an infection. EBP entailed wearing a gown and gloves during high contact activities.

In an interview 8/28/25 at 10:15 AM, the Director of Nursing (DON) reported he expected EBP implemented anytime staff took care of a resident who had a catheter or a wound. Staff should wear PPE gown and gloves for EBP. The DON reported he also expected gloves changed whenever staff removed a dressing and anytime going between steps or a clean area. Staff should change gloves and sanitize their hands, then put a clean dressing on.

An Infection Control Standard and Transmission-Based Precautions policy reviewed 8/2024 revealed infection control measures implemented to prevent the spread of diseases and conditions. Section 3 revealed EBP's used in conjunction with standard precautions and expanded the use of gown and gloves

during high-contact resident care activities (for example when cared for residents with wounds and indwelling medical devices due to the high risk of acquisition and colonization of Mulit-Drug Resistant Organisms (MDRO's). Personal Protective Equipment (PPE) donned upon room entry, then doffed and properly discarded, and hand hygiene performed before exiting the room to contain pathogens.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet