Greater Southside Health And Rehabilitation
Greater Southside Health and Rehabilitation in Des Moines, IA — inspection on September 3, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
165175 09/03/2025
Greater Southside Health and Rehabilitation 5608 SW 9th Street Des Moines, IA 50315
treatments and perform dressing changes as ordered by the physician for one of four residents
Significant change in status Minimum Data Set (MDS) assessment dated [DATE] 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.
165175 09/03/2025
Greater Southside Health and Rehabilitation 5608 SW 9th Street Des Moines, IA 50315
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.
165175 09/03/2025
Greater Southside Health and Rehabilitation 5608 SW 9th Street Des Moines, IA 50315
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.
- The Quarterly MDS assessment dated [DATE] 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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.