Greater Southside Health And Rehabilitation

to the Administrator and the State Survey Agency.

needed to be reported to DIAL.

• The Minimum Data Set (MDS) dated [DATE] 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] 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 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.

165175 10/27/2025

Greater Southside Health and Rehabilitation 5608 SW 9th Street Des Moines, IA 50315

Review of facility policy titled, Reporting

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.

165175 10/27/2025

Greater Southside Health and Rehabilitation 5608 SW 9th Street Des Moines, IA 50315

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].

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.

165175 10/27/2025

Greater Southside Health and Rehabilitation 5608 SW 9th Street Des Moines, IA 50315

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.