Greater Southside Health And Rehabilitation

F 0600

included LPN Staff A said, do not give him shit. CMA, Staff C reported much cussing back and forth, walked away as was instructed to do by Staff A .

Level of Harm - Actual harm Residents Affected - Few

During an interview on 10/20/25 at 3:40 PM R#3 relayed while at the facility received only one time in the middle of the night pain medication and had a lot of pain, reported on 10/10/25 asked for the Administrator and Staff A responded, what do you want, I am all you got, was screaming back and forth. Staff F said don't give this mother f***r anything and left

During an interview with LPN, Staff A on 10/21/25 at 1:50 PM relayed CMA ,Staff C asked for assistance on 10/10/21 sometime after 4:00 PM because CMA, Staff C was afraid of Resident R3# due to his anger. R#3 complained is not getting pain medications. Relayed met with R#3 in his room, voices were raised, tired of R#3 repeated profanities, so just walked out.

During an interview on 10/21/25 at 6:11 PM LPN Staff D relayed on 10/9/25 R#3 asked for pain medication, Staff D responded medications had not arrived from the pharmacy. Staff D reported left in the morning of 10/10/25 when the shift ended, still had not received the orders from the hospital.

During an interview with the Administrator on 10/27/25 at 2:30 PM was relayed would have expected staff to inform her directly right away of verbal altercation and resident allegations of abuse that transpired on 10/10/25.

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

10/27/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm

1. 4. Ensure that the results of all investigations are reported within five (5) working days of the incident to the

Administrator and the State Survey Agency.

During an interview on 10/23/25 at 1:45 PM, the Director of Nursing revealed any allegations of abuse needed to be reported to DIAL.

Residents Affected - Few

2. 3. The Minimum Data Set (MDS) dated [DATE REDACTED] reflected admission to the facility, from the hospital and

documented basic demographics for R#3 coded as an entry tracking record.

The Clinical Assessment List for R#3 documented a Brief Interview for Mental Status (BIMS) assessment dated [DATE REDACTED] revealed resident scored 13 out of 15 indicated is cognitively intact. The Electronic file lacked care plan documentation.

A facility document, Self Report, 5 day summary relayed on 10/13/25 the Administrator received a phone call from R#3 alleging abuse by Licensed Practical Nurse (LPN) Staff A, alleged Staff A withheld medication and used profanities towards him. Findings noted, after the investigation was determined R#3 experienced poor services. Corrective action included all staff educated on reporting abuse.

A statement (not dated) from Certified Medication Aide (CMA) Staff B documented on 10/10/25 heard LPN Staff A and R#3 yelling. R#3 said you do not control my medications. Staff A responded, followed the doctors orders so yes does control medications. Staff B heard Staff A verbalize as left the room, the way R#3 is acting, is not getting his fucking oxy , referred to oxycodone pain medication.

A statement from CMA, Staff C dated 10/15/25 documented on 10/10/25 relayed Staff C asked by a therapy staff if R#3 could have pain medication. Replied yes and would be there when the current task finished. Therapy staff came back and informed R#3 is upset. CMA Staff C summoned the LPN, Staff A who entered R#3 room while CMA waited outside. Staff C relayed much yelling back and forth included LPN Staff A commented, do not give him shit. CMA Staff C reported much cussing back and forth so walked away.

An interview with LPN, Staff A on 10/21/25 at 1:50 PM relayed CMA Staff C summoned her on 10/10/21 sometime after 4:00 PM to assist because Staff A was afraid of Resident R3# who was angry, complaining is not getting pain medications. Relayed met with R#3 in his room yelled profanities in turn Staff A relayed did raise voice, tired of R#3 repeated profanities, so I just walked out.

An interview with the Administrator on 10/27/25 at 2:30 PM Administrator relayed would have expected staff to inform her directly right away of verbal altercation and resident allegations on 10/10/25, instead heard from R#3 on 10/13/25. The Administrator relayed understood the obligation to report timely allegations of abuse.

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

10/27/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

to her by Staff H in regard to the incident. During an interview on 10/21/25 at 1:35 PM, the Administrator confirmed a facility investigation had not been completed in regard to the 10/14/25 incident involving Resident #1 and Resident #2. Review of the clinical record for Resident #1 lacked documentation regarding

the 10/14/25 incident with Resident #2 including care plan updates, completion of an incident report and completion of a resident assessment. Review of the clinical record for Resident #2 lacked documentation regarding the 10/14/25 incident with Resident #1 including care plan updates related to hypersexual behavior until 10/19/25, completion of an incident report and completion of a resident assessment. Review of facility policy titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised 8/2024 revealed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, resident representatives, families, friends or other individuals. If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by State and Federal Law. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will ensure that after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). Ensure that the results of all investigations are reported within five (5) working days of the incident to the Administrator and the State Survey Agency. During an interview on 10/23/25 at 1:45 PM, the Director of Nursing (DON) revealed the expectation in regard to allegations of abuse is to notify the Abuse Coordinator/Administrator, report the incident to DIAL, complete a facility investigation which would include staff interviews and a 5 day summary. The DON further revealed charting, completion of an incident report, documentation of resident to resident interactions, care plan updates with new interventions that are put in place related to the incident, and timely family notification would also take place.

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

10/27/2025

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 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

the facility on [DATE REDACTED]. Staff K was told when the job started, the floor nurses do not do the admission work, was not sure which of management staff was responsible for R#3 admission paperwork. Did not have a diet order but looked at a diagnosis list and decided to give a regular room tray. Staff K relayed shift ended at 7:30 PM and reported to next shift nurse, LPN Staff D of the new admission. During an interview on 10/21/25 at 6:11 PM LPN, Staff D stated the 10/9/25 shift began at 6:00 PM and was informed had a new admit. R#3 asked for pain medication about 6:00 PM, called the Director of Nursing for R#3 orders and was informed, Registered Nurse (RN) Staff G would be entering the orders into the system. Told R#3 the medications had not arrived from the pharmacy. Staff D relayed did have 4 medications that arrived earlier from the pharmacy included oxycodone for pain but did not have the physician orders. Called Staff G who instructed to give the medications that arrived from the pharmacy. Staff D relayed did not feel comfortable with no orders in the system. Staff D stated called the on-call Nurse Practitioner (NP) Staff J who gave an order for 10 milligrams of oxycodone since R#3 was in so much pain. Staff D relayed also called the hospital for orders to be faxed. Staff D reported left in the morning of 10/10/25 when the shift ended, still had not received the orders from the hospital, was not even sure the fax was working. During an interview

on 10/23/25 at 9:25 AM Corporate Registered Nurse (RN), Staff G relayed R#3 arrived at the facility between 3-4:00 PM, had agreed to enter the admission orders. Staff G reported received via e-mail the orders from the Assistant Director of Nurses (ADON) that did not include medication orders and could not add orders in the system. Staff G stated Staff D called about 11:00 PM relaying R#3 had no orders and was having pain. Staff G instructed Staff D to give the oxycodone that arrived from the pharmacy and to get all orders from the hospital. Staff G stated discovered the next morning when arrived to the facility that R#3 orders still were not received. Staff G agreed the delay in getting orders caused R#3 unnecessary pain, to not have blood sugar checks (for diabetes monitoring) and R#3 did not get the evening dose of insulin on 10/9/25 or morning insulin on 10/10/25. During an interview with Pharmacist, Staff F on 10/27/25 at 9:56 AM confirmed received admission orders from the facility system on 10/10/25 for R#3 who admitted on [DATE REDACTED]. Pharmacist, Staff F relayed would have expected a call from the facility if there were any concerns regarding medications. Staff F relayed the facility has an emergency kit of medications to use or could call

the pharmacy 24 hour on call option. Staff F relayed a concern with the process was evident regarding R#3 admission. The policy titled Procedure, Nursing Administration, Subject of Admission, last revision 7/2023 included to : Minimize resident stress with transition, provide information and resources for care, comfort and federal and state requirements. Provide safety of possessions, obtain information about the resident to establish baseline data, provide the basis for interdisciplinary assessment, care planning and rehabilitation.

Included to:1. Inform physician of admission and verify transfer and admission orders.2. Initiate any required treatments as ordered3. Order medications from pharmacy4. Initiate admission assessments5.

Initiate Resident Care Plan.

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

10/27/2025

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 0697 Level of Harm - Minimal harm or potential for actual harm

An interview with Pharmacist, Staff F on 10/27/25 at 9:56 AM confirmed received admission orders from

the facility system on 10/10/25 for R#3 who admitted on [DATE REDACTED]. Pharmacist, Staff F relayed would have expected a call from the facility if there were any concerns regarding medications. Staff F relayed the facility has an emergency kit of medications to use or could call the pharmacy 24 hour on call option. Staff F relayed a concern with the process was evident regarding R#3 admission.

Residents Affected - Few

A Policy titled: Nursing Administration, Subject: Pain documented, The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by screening, assessing, identifying circumstances and by developing and implementing a plan, using pharmacologic and/or non-pharmacologic interventions to manage the pain and/or try to prevent the pain consistent with

the resident's goals. Staff directed to document, monitor, treat and consult with the physician to evaluate and revise as indicated.

1. 2. The MDS dated [DATE REDACTED] revealed R#4 had a BIMS of 14 indicating intact cognition. The MDS further

revealed the resident had diagnoses including acute osteomyelitis (inflammation of bone) in the right ankle and foot, pain in the right and left knee and required scheduled pain medication regimen in addition to as needed pain medication.

The Care Plan initiated 8/24/25 revealed R#4 had acute/chronic pain and directed staff to administer analgesia medication per orders and half an hour before treatments or care.

Clinical census for R#4 revealed an admission date of 8/22/25.

Review of Encounter Note dated 8/29/25 completed by Staff J, Nurse Practitioner (NP) revealed R#4 reported pain to be 10/10. Staff J documented an order to restart Oxycodone 5 milligrams (mg) every 6 hours as needed.

During an interview 10/22/25 at 11:40 AM, Staff J, NP revealed a nurse had called her the week of 9/2/25 reporting they did not have an as needed order for R#4's Oxycodone. Staff J reported she was upset someone had not called her over the weekend as she would have given a verbal order for the Oxycodone.

Staff J verified she had originally re-ordered the Oxycodone on 8/29/25 after a visit with R#4 and the information was documented in her notes.

Review of Clinical Physician Orders for R#4 revealed the order for Oxycodone 5 mg every 6 hours as needed was initiated 9/4/25.

During an interview 10/22/25 at 12:50 PM, R#4 revealed when he first arrived at the facility his hip pain was unbearable and he didn't get much help with pain control except Tylenol. Stated he got an order for more pain medication from the NP and the pain control improved.

During an interview 10/22/25 at 3:25 PM, the Director of Nursing (DON) revealed the as needed Oxycodone should have been transcribed when it was received. The DON revealed he was not sure when

the breakdown happened but is looking at improving the process.

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

Event ID:

Facility ID:

If continuation sheet