Inspection Reports for Greater Southside Health and Rehabilitation
5608 SW Ninth Street, Des Moines, IA, 503150000
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 25, 2025 found the facility in substantial compliance with all previously cited deficiencies corrected. Earlier inspections showed a pattern of deficiencies related primarily to resident abuse and neglect, failure to report and investigate abuse allegations timely, and issues with medication management and infection control. Several complaint investigations were substantiated, including cases involving resident rights violations, inadequate care, and safety concerns, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility demonstrated improvement over time, with multiple plans of correction accepted and subsequent re-inspections confirming compliance. While some issues have recurred, recent inspections suggest corrective actions have been effective in addressing prior deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
264% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
71 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 25, 2025
Visit Reason
A revisit of the survey ending October 27, 2025 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 14, 2025.
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 5
Date: Oct 27, 2025
Visit Reason
The inspection was conducted as a result of complaints #2613240-C, #2640175-C, and #2644957-C, and a facility reported incident #2645791-1, all investigated between October 20, 2025 and October 27, 2025.
Complaint Details
The investigation was complaint-driven based on complaints #2613240-C, #2640175-C, and #2644957-C, and a facility reported incident #2645791-1. The complaints and incident resulted in deficiencies related to abuse and neglect. The facility failed to report allegations of abuse to the Department of Inspections, Appeals and Licensing (DIAL) in a timely manner and failed to complete thorough investigations. The complaint was substantiated as evidenced by the findings.
Findings
The facility was found to have deficiencies related to failure to ensure residents were free from abuse, failure to report allegations of abuse in a timely manner, failure to complete thorough investigations, failure to ensure full admission orders, and failure to provide appropriate pain medications. The facility reported a census of 71 residents during the investigation.
Deficiencies (5)
Failure to ensure resident’s free from abuse
Failure to report allegations of abuse to DIAL in a timely manner
Failure to complete a thorough investigation
Failure to ensure full admission orders for Resident #3
Failure to provide appropriate pain medications
Report Facts
Deficiencies cited: 5
Census: 71
Residents reviewed: 3
Residents reviewed for pain management: 3
Residents affected: 4
Medication doses: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in findings related to withholding medication and profanities towards Resident #3 |
| Staff B | Certified Medication Aide (CMA) | Reported witnessing abuse and profanities, educated on reporting allegations |
| Staff C | Certified Medication Aide (CMA) | Reported witnessing abuse and profanities, educated on reporting allegations |
| Staff H | Certified Nurse Aide (CNA) | Witnessed incident involving Residents #1 and #2, documented statements |
| Staff I | Licensed Practical Nurse (LPN) | Witnessed incident, reported to Administrator, signed statements |
| Staff D | Licensed Practical Nurse (LPN) | Reported medication issues and resident pain management |
| Staff F | Pharmacist | Confirmed medication orders and relayed concerns about medication process |
| Staff G | Registered Nurse (RN) | Entered medication orders and relayed admission orders |
| Staff J | Nurse Practitioner (NP) | Involved in care plan and medication orders |
| Executive Director | Educated on reporting allegations of abuse | |
| Director of Nursing | DON | Revealed expectation to report abuse and monitor investigations |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction indicating acceptance of the facility's credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification of compliance effective September 18, 2025. No specific deficiencies are detailed in the report.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 4
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as a result of complaints #1739137-C, #1739138-C, #2588611-C, #2599989-C, and #2601923-C, as well as facility-reported incidents #256833.1, #2589139-L, and #2599148-L, during the period from August 25, 2025 to September 2, 2025.
Complaint Details
The investigation was complaint-driven based on multiple complaints and facility-reported incidents. Complaints #2599111-C and incident #2562833-I did not result in deficiencies. The substantiation status for the other complaints is not explicitly stated.
Findings
The facility was found to have multiple deficiencies related to resident rights, quality of care, sufficient nursing staff, and infection prevention and control. Specific issues included failure to maintain resident dignity and privacy, lapses in adherence to physician orders and care planning, insufficient staffing levels impacting resident care, and inadequate infection control practices including enhanced barrier precautions.
Deficiencies (4)
Failure to ensure resident dignity and privacy, including exposed resident buttocks and lapses in appropriate clothing and coverings.
Failure to administer treatments and perform dressing changes as ordered by the physician, including inadequate wound care.
Insufficient nursing staff to meet resident needs, resulting in delayed call light responses and unmet assistance with feeding.
Failure to establish and maintain an infection prevention and control program, including lapses in enhanced barrier precautions and PPE use.
Report Facts
Census: 70
Deficiencies cited: 4
BIMS score: 15
Completion date: Sep 18, 2025
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
The inspection was conducted from June 26, 2025 to June 30, 2025 for the investigation of Complaint #129613-C.
Complaint Details
Investigation of Complaint #129613-C; facility found in compliance.
Findings
The Greater Southside Health and Rehabilitation was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities during the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 23, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance with health requirements.
Findings
The facility was found to be in substantial compliance with health requirements as of June 23, 2025, based on acceptance of the Plan of Correction.
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 13
Date: Jun 10, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of multiple complaints and facility reported incidents.
Complaint Details
The inspection included investigation of Complaints #128530-C, #128537-C, and #128723-C. Each complaint resulted in a deficiency. Facility reported incidents #128629-I and #128844-I resulted in no deficiency.
Findings
The facility was found deficient in multiple areas including failure to document accurate code status for residents, failure to ensure timely follow-up for PRN psychotropic medications, inaccurate Minimum Data Set (MDS) assessments, incomplete baseline care plans, failure to carry out therapy recommendations and restorative exercises, failure to offer meals or snacks to residents who missed scheduled mealtimes, medication errors, improper medication storage, failure to meet nutritional needs and preferences in meal preparation, failure to maintain sanitary food preparation conditions, failure to serve correct food textures, failure to verify patient identifiers before sending transfer paperwork, and failure to follow infection control standards including proper use of PPE and sanitizing equipment.
Deficiencies (13)
Failure to document accurate code status for 2 of 18 residents reviewed (#30 and #52).
Failure to ensure timely follow-up for initiation of PRN psychotropic drug for 1 of 5 residents reviewed (#37).
Failure to accurately reflect status of 3 of 3 residents in MDS assessments (#11, #13, #37).
Failure to complete baseline care plan within 48 hours of admission for 1 of 2 residents reviewed (#223).
Failure to carry out therapy recommendations and provide restorative exercises for 1 of 2 residents reviewed (#30).
Failure to offer morning meal or snack to a resident (#8).
Medication error rate of 7% observed with errors for Resident #45 and Resident #11.
Failure to securely store medications for 1 of 7 residents observed during medication administration (#34).
Failure to ensure lunch menu and meal met nutritional needs and preferences for 7 of 68 resident lunch trays prepared.
Failure to ensure a resident was served the correct food texture for 1 of 2 residents on a puree diet (#47).
Failure to maintain clean and sanitary kitchen conditions, label and store food properly, and thaw food safely.
Failure to follow infection control standards including proper use of PPE and sanitizing mechanical lift between residents (#33 and #54).
Failure to verify patient identifiers before sending transfer paperwork, resulting in receiving facility obtaining inaccurate medical records for Resident #172.
Report Facts
Deficiencies cited: 12
Medication error rate: 7
Residents on psychotropic medications reviewed: 5
Residents on puree diet: 2
Residents on liquefied diet: 1
Residents reviewed for discharge planning: 3
Residents reviewed for MDS accuracy: 3
Residents reviewed for baseline care plan: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse | Named in medication administration error and infection control findings. |
| Staff C | Certified Medication Aide | Named in medication administration error finding. |
| Staff E | Certified Medication Aide | Named in medication storage finding. |
| Staff F | Certified Nursing Assistant | Named in infection control findings related to catheter care. |
| Staff G | Certified Nursing Assistant | Named in infection control findings related to catheter care. |
| Staff H | Certified Medication Aide | Named in restorative care findings. |
| Staff I | Certified Nursing Assistant | Named in restorative care findings. |
| Staff J | Physical Therapist | Named in restorative care findings. |
| Staff L | Cook | Named in food preparation and meal service findings. |
| Staff M | Certified Nursing Assistant | Named in nutrition and infection control findings. |
| Staff N | Dietary Aide | Named in food service hand hygiene finding. |
| Staff P | Certified Nursing Assistant | Named in infection control findings. |
| Director of Nursing | Director of Nursing | Named in multiple findings including medication errors, restorative care, infection control, and transfer paperwork. |
| Certified Dietary Manager | Certified Dietary Manager | Named in food service and nutrition findings. |
| Social Services Supervisor | Social Services Supervisor | Named in transfer paperwork findings. |
| Administrator | Administrator | Named in transfer paperwork findings. |
| ARNP | Advanced Registered Nurse Practitioner | Named in transfer paperwork findings. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective May 13, 2025. No specific deficiencies are detailed in this report.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as a result of Complaint #128140-C, investigating the facility's failure to identify and report ongoing abnormal vital signs and complete respiratory assessments for two residents.
Complaint Details
Complaint #128140-C was substantiated, resulting in deficiencies related to quality of care concerning abnormal vital signs monitoring and reporting.
Findings
The facility failed to identify and report abnormal vital signs for Resident #1 and Resident #2, and failed to complete respiratory assessments for Resident #1 despite signs of shortness of breath. Documentation lacked timely physician notification of abnormal vital signs, and Resident #2 experienced multiple falls and an unplanned hospital transfer resulting in death.
Deficiencies (2)
Failed to identify and report ongoing abnormal vital signs for 2 of 2 residents.
Failed to complete respiratory assessment for Resident #1 when identified as short of breath on exertion for 5 out of 10 days reviewed.
Report Facts
Resident census: 68
Dates with documented shortness of breath: 5
Dates with abnormal vital signs: 9
Dates with low heart rate: 14
Falls: 3
Days of antibiotic treatment ordered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported Resident #1's condition on 4/21/25 and decision to send to hospital |
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #1 on 4/21/25 and reported observations of condition |
| Staff C | Licensed Practical Nurse (LPN) | Confirmed working with Resident #2 on 4/20/25 and described events leading to hospital transfer |
| Staff E | Certified Medication Assistant (CMA) | Administered medications to Resident #2 and reported on vital sign monitoring |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for vital sign monitoring and physician notification |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Described nurse responsibilities for physician notification of abnormal vital signs |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 31, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective March 31, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 4
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#125938-C, 126151-C, 126365-C, 127192-C, 127282-C, 127335-C) and facility reported incidents (#127253-I, #127254-I, #127364-I) from March 17 to March 20, 2025.
Complaint Details
Complaints #125938-C, 126151-C, 126365-C, 127192-C, 127282-C, 127335-C were substantiated. Complaint #126351-C was unsubstantiated. Facility Reported Incidents #127253-I, #127254-I, #127364-I were substantiated.
Findings
The facility was found to have deficiencies related to resident rights, abuse and neglect, dialysis care, and resident call system functionality. Some complaints and incidents were substantiated while others were not. The facility has implemented corrective actions including staff education and policy reinforcement with completion dates by 03/31/2025.
Deficiencies (4)
Failure to treat residents with respect and dignity by entering rooms without knocking and not ensuring appropriate clothing for weather conditions.
Failure to protect residents from abuse and neglect, including misappropriation of resident property by staff.
Failure to ensure residents who require dialysis receive consistent pre- and post-dialysis assessments.
Failure to provide a properly functioning resident call system for multiple residents.
Report Facts
Complaint numbers investigated: 6
Facility Reported Incidents investigated: 3
Resident census: 70
Residents directly affected by dignity and respect issue: 3
Residents reviewed for abuse and neglect: 3
Resident dialysis assessments reviewed: 1
Residents affected by call system malfunction: 1
Missing cash amount: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nurses Aide (CNA) | Involved in misappropriation of resident property incident |
| Staff A | Activity Department Staff | Observed entering resident room without knocking |
| Staff B | Certified Nursing Assistant (CNA) | Entered resident room without knocking and apologized |
| Staff E | Licensed Practical Nurse (LPN) | Responsible for dialysis assessments and treatment documentation |
| Staff C | Certified Nursing Staff | Tested resident call light system |
| Staff D | Business Office Manager | Reported call light malfunction and observed resident call issues |
| Director of Nurses (DON) | Director of Nursing | Reviewed dialysis assessment process and identified incomplete assessments |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
A revisit of the survey ending November 13, 2024 and investigation of complaints #125210-C and #125541-C was conducted on December 30, 2024-January 2, 2025.
Complaint Details
Complaints 125210-C and #125541-C were investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 16, 2024. Complaints 125210-C and #125541-C were not substantiated.
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 2
Date: Nov 13, 2024
Visit Reason
The inspection was a revisit following a prior survey ending October 2, 2024, and was conducted in response to complaints and facility-reported incidents related to accident hazards, specifically concerning water temperature in the shower room that caused injury to Resident #2.
Complaint Details
The visit was triggered by complaints #123862-C, 123904-C, 124259-C, 124502-C, 124645-C and facility reported incidents 124669-I and 124792-I. Complaints #123862-C, 123904-C, and 124502-C were substantiated.
Findings
The facility failed to ensure a safe environment free of accident hazards, resulting in a resident sustaining a second-degree burn from excessively hot water in the shower room. The facility implemented immediate corrective actions including shutting down the shower, staff education, plumbing repairs, and ongoing monitoring of water temperatures. The scope of the deficiency was lowered after these measures were verified.
Deficiencies (2)
Failure to ensure the resident environment remains free of accident hazards, resulting in a resident sustaining a 2nd degree burn from hot water in the shower room.
Failure to ensure residents who require dialysis receive services consistent with professional standards and person-centered care.
Report Facts
Water temperature measured: 145.2
Facility census: 59
Number of residents showered before water shut down: 3
Water temperature maximum allowed: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Nurse Practitioner | Notified of resident's skin wound and followed up on condition |
| Staff D | Licensed Practical Nurse (LPN) | Notified of resident injury and water temperature issue |
| Staff B | Certified Nursing Assistant (CNA) | Assisted resident to shower and involved in water temperature incident |
| Staff E | Licensed Practical Nurse (LPN) | Notified of resident burn and skin condition, communicated with family and staff |
| Staff K | Certified Nursing Assistant (CNA) | Reported shower water temperature concerns |
| Staff M | Certified Nursing Assistant (CNA) | Assisted resident with shower and reported observations |
| Staff L | Occupational Therapist (OT) | Assisted resident after shower and noted skin condition |
| Staff F | Certified Nursing Assistant (CNA) | Reported water temperature issues in shower rooms |
| Staff G | Certified Medication Aide (CMA) | Reported communication about shower water temperature problem |
| Staff A | Certified Medication Aide (CMA)/Driver | Transported residents to dialysis appointments |
| Staff I | Certified Nursing Assistant (CNA) | Reported on shower room safety and resident care |
| Staff B | Certified Nursing Assistant (CNA) | Assisted resident with shower and bowel care |
| Staff E | Licensed Practical Nurse (LPN) | Assessed resident's skin condition and communicated with family and staff |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 8
Date: Oct 2, 2024
Visit Reason
Investigation of multiple complaints (#123232-C, #123325-C, #123319-C, #123468-C, #123527-C, #123542-C, #123613-C, and #123660-C) conducted from September 18, 2024 to October 2, 2024.
Complaint Details
The visit was complaint-related based on investigation of Complaints #123232-C, #123325-C, #123319-C, #123468-C, #123527-C, #123542-C, #123613-C, and #123660-C. Complaints #123232-C, #123325-C, #123468-C, #123527-C, #123613-C, and #123660-C were substantiated.
Findings
The facility had multiple deficiencies including failure to ensure resident representative rights, failure to notify family of medication changes, failure to follow physician orders, failure to provide timely assessment and intervention resulting in harm, failure to maintain competent nursing staff, failure to secure medication carts, and failure to safeguard resident-identifiable information.
Deficiencies (8)
Failure to ensure resident representative rights for Resident #10.
Failure to notify family/representative of medication change for Resident #1.
Failure to follow physician orders and document appropriately for Residents #2 and #8.
Failure to provide assessment and intervention for necessary care resulting in harm to Resident #10 and failure to provide wound vac care for Resident #4.
Failure to ensure oxygen was available to Resident #9 requiring oxygen therapy.
Failure to maintain competent nursing staff to perform enema and wound vac care for Residents #10 and #4.
Failure to properly secure medication carts from unauthorized access.
Failure to safeguard resident-identifiable information from unauthorized access.
Report Facts
Deficiencies cited: 8
Resident census: 67
Oxygen liter flow order: 4
Enema order frequency: 3
Wound vac treatment frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Practical Nurse | Named in findings related to Resident #10's condition and communication with family. |
| Staff F | Licensed Practical Nurse | Named in enema procedure deficiency for Resident #10. |
| Staff I | Licensed Practical Nurse | Named in failure to notify family of medication change for Resident #1. |
| Assistant Director of Nursing | Named in multiple findings including order entry, wound vac care, oxygen tank replacement. | |
| Director of Nursing | Named in multiple findings including order verification, wound vac care, medication cart security, and resident information protection. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
An on-site revisit was conducted from September 18, 2024 to September 19, 2024 for the survey ending August 29, 2024.
Findings
No concerns were noted during the revisit and based on the correction date on the plan of correction, the facility will be certified in compliance effective September 12, 2024.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
An on-site revisit was conducted on July 25, 2024 for the Recertification and Complaint Survey completed July 12, 2024.
Findings
No concerns were observed and all deficiencies were corrected; the facility will be certified in compliance effective July 23, 2024.
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 4
Date: Jul 12, 2024
Visit Reason
The inspection was conducted as an Annual Recertification survey and investigation of Complaints #121548-C, #121702-C, and #121818-C at Genesis Senior Living.
Complaint Details
Complaint #121702-C was substantiated.
Findings
The facility failed to complete required Level II PASRR screenings for certain residents, did not hold timely care plan conferences for some residents, and failed to provide adequate grooming and nail care for dependent residents. Additionally, the facility failed to safely serve therapeutic diets according to physician orders for some residents.
Deficiencies (4)
Failed to refer two residents for Level II PASRR screening despite known serious mental disorders.
Failed to develop and implement baseline care plans including timely care plan conferences for residents.
Failed to provide necessary grooming services including nail care for dependent residents.
Failed to safely serve therapeutic diets according to physician orders, resulting in choking risk for a resident.
Report Facts
Complaint numbers investigated: 3
Resident census: 60
Residents on mechanically altered diet: 16
Residents reviewed for deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Reported PASRR screening issues and acknowledged Level II PASRR screening requirements | |
| Administrator | Provided education on PASRR audit tool and care plan conference requirements | |
| Director of Nursing | Provided education on ADL care and diet order compliance; monitored for compliance | |
| Assistant Director of Nursing (ADON) | Reported on care conference documentation and shower sheet expectations | |
| Registered Dietitian | Conducted audits and education on diet texture and meal service | |
| Speech Language Pathologist | Provided recommendations and education regarding resident diet and swallowing safety | |
| Certified Medication Aide (CMA) | Reported on diet change notification system and meal time monitoring | |
| Certified Nursing Assistants (CNAs) | Observed for compliance with nail care and meal service |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 14, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance and certification effective June 14, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, with the Directed Plan of Nursing Assistance (DPNA) effectuated from May 28, 2024 to June 13, 2024.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 4
Date: Jun 3, 2024
Visit Reason
The inspection was a revisit of the survey ending 4/19/24 and an investigation of Complaint #120390-C, conducted from May 29, 2024 to June 3, 2024.
Complaint Details
Complaint #120390-C was substantiated based on findings including failure to notify family of change in condition and unsafe transport practices.
Findings
The facility was found deficient in notifying a resident's family of a change in condition, maintaining clean and well-repaired bathrooms, meeting professional standards in care including timely meal delivery after insulin administration and audiology services, and ensuring resident safety during transport with properly secured wheelchair brakes.
Deficiencies (4)
Failed to notify the family of a resident's change in condition for 1 of 3 residents reviewed.
Failed to ensure bathroom surfaces were clean and tile in good repair for 4 of 4 resident bathrooms observed.
Failed to follow professional standards by failing to carry out leg wraps as ordered, failing to ensure a resident received a meal in a timely manner after receiving insulin, and failing to ensure provision of audiology services for 1 of 3 residents reviewed.
Failed to ensure a resident was secured in a van during transport causing injury due to unsecured wheelchair brakes.
Report Facts
Census: 59
Deficiencies cited: 4
Units audited: 5
Date of Allegation of Compliance: Jun 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in failure to carry out leg wraps and insulin administration findings |
| Staff B | Certified Nursing Assistant (CNA) | Named in transport incident and meal delivery findings |
| Staff C | Maintenance Supervisor (MS) | Named in wheelchair brake repair and transport incident findings |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including notification, professional standards, and transport safety |
| Dietary Manager | Named in meal delivery findings |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Apr 19, 2024
Visit Reason
The inspection was conducted due to facility complaints #119993-C, #119996-C, and #120067-C from April 8 through April 19, 2024, to investigate quality of care concerns including failure to properly assess residents and manage changes in condition.
Complaint Details
The investigation was triggered by complaints alleging inadequate care and failure to assess residents properly, substantiated by findings of Immediate Jeopardy that was later removed after corrective actions.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483 requirements, specifically failing to provide adequate assessment and interventions for residents with condition changes, resulting in serious health declines and one resident's death from sepsis. The facility initially had an Immediate Jeopardy situation which was removed after corrective actions. Multiple failures in assessment, documentation, and treatment were documented, including inadequate wound care and failure to monitor critical lab values.
Deficiencies (1)
Failure to properly assess and intervene for residents with changes in condition, including inadequate wound care and monitoring of critical lab values.
Report Facts
Census: 58
PT/INR reading: 7.3
PT/INR therapeutic range: 2
PT/INR therapeutic range: 3
Wound size: 4.5
Wound size: 5
BIMS score: 8
BIMS score: 9
Audit frequency: 5
Audit duration: 4
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Assistant Director of Nursing | Mentioned in relation to wound assessment and communication with NP |
| Staff B | Registered Nurse | Provided statements about wound observations and assessment practices |
| Staff C | Certified Nursing Assistant | Reported observations of resident's wounds and communication with family |
| Staff D | Registered Nurse | Attempted blood draws and reported resident's arm swelling |
| Director of Nursing | Director of Nursing | Confirmed failures in resident assessment and lack of policy on condition change assessment |
| NP | Nurse Practitioner | Interviewed regarding resident assessments, wound observations, and communication with hospital |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective April 2, 2024.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Date: Mar 11, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations and a facility reported incident between March 4, 2024 and March 11, 2024. Complaints #115516-C, #117770-C, #118656-C, and #119320-C were substantiated.
Complaint Details
Complaints #115516-C, #117770-C, #118656-C, and #119320-C were substantiated as part of the investigation conducted from March 4 to March 11, 2024.
Findings
The facility failed to follow physician orders for medication administration for Resident #4, with missing documentation and lack of physician notification. Additionally, the facility failed to provide safe mechanical lift transfers for Residents #1 and #5 by locking the lift wheels during transfers contrary to manufacturer recommendations.
Deficiencies (2)
Facility failed to follow physician orders for Resident #4 by omitting medication administration without documentation or physician notification.
Facility failed to provide safe mechanical lift transfers for Residents #1 and #5 by locking the lift wheels during transfers, contrary to manufacturer guidelines.
Report Facts
Resident census: 62
Medication omission days: 15
Residents reviewed for lift transfers: 3
Residents with deficient lift transfers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed locking lift wheels during mechanical lift transfers contrary to guidelines |
| Staff D | Registered Nurse | Provided training on mechanical lift transfers and commented on policy clarity |
| Staff E | Certified Medication Aide (CMA) | Reported on medication administration and pharmacy issues for Resident #4 |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding medication administration and mechanical lift transfer expectations |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was certified in compliance effective October 11, 2023, based on acceptance of the credible allegation and Plan of Correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 5
Date: Sep 7, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from September 5, 2023 to September 7, 2023.
Findings
The facility was found deficient in several areas including failure to provide reasonable accommodations for residents' needs, failure to notify the Long Term Care Ombudsman of resident transfers, failure to coordinate PASARR assessments, failure to revise care plans timely, and failure to provide restorative therapy to residents with limited range of motion.
Deficiencies (5)
Failure to accommodate Resident #33's needs for an adaptive call light device due to bilateral hand contractures.
Failure to notify the Long Term Care Ombudsman for Resident #47's hospital transfer.
Failure to refer Resident #18 for Level II PASARR evaluation despite a new psychiatric diagnosis.
Failure to revise Resident #18's comprehensive care plan to reflect current psychiatric diagnosis in a timely manner.
Failure to provide restorative therapy to Resident #43 with limited range of motion due to stroke and hemiplegia.
Report Facts
Deficiencies cited: 5
Resident census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged Resident #33's inability to use current call light device and need for adaptive device |
| Administrator | Administrator | Acknowledged Resident #33's call light issues and failure to notify Ombudsman for Resident #47 |
| Social Services Director | Social Services Director | Discussed PASARR updates and facility policy |
| MDS Coordinator | MDS Coordinator | Verified care plan deficiencies for Resident #18 |
| Interim Director of Nursing | Interim Director of Nursing | Discussed restorative therapy orders and interdisciplinary team meetings |
| Restorative Aide | Restorative Aide | Stated Resident #43 has never had a restorative program |
| Regional Assessment Coordinator | Regional Assessment Coordinator | Discussed PASARR policies and restorative program evaluations |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 8
Date: Jun 20, 2023
Visit Reason
The inspection was conducted as a result of complaints #1113653-C and #1113654-C, with the investigation period from June 21, 2023 to July 13, 2023, focusing on resident rights, employment practices, care plan timing and revision, quality of care, accident hazards, pain management, infection control, and abuse/neglect.
Complaint Details
Complaint #1113653-C was substantiated. The investigation included observations, interviews, and record reviews related to resident rights violations and other care concerns.
Findings
The facility was found to have multiple deficiencies including failure to respect resident dignity and privacy, failure to employ staff with proper background checks, inadequate care plan development and revision, failure to meet professional standards in services provided, failure to prevent accidents, inadequate pain management, infection control lapses, and failure to protect residents from abuse and neglect. The facility reported a census of 62 residents during the investigation.
Deficiencies (8)
Failure to provide dignity and privacy to residents, including use of inappropriate language by staff and exposure of residents during care.
Failure to employ staff with valid background checks and work authorization.
Failure to develop and revise comprehensive care plans timely and accurately for residents.
Failure to meet professional standards in medication administration and treatment.
Failure to ensure resident safety and prevent accidents related to mechanical lifts and incontinence care.
Failure to adequately manage resident pain, including failure to administer prescribed pain medications.
Failure to establish and maintain an effective infection prevention and control program.
Failure to protect residents from abuse, neglect, and exploitation, including failure to provide required staff training.
Report Facts
Census: 62
Complaint IDs: 2
Dates of Investigation: 23
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 13
Date: Apr 27, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints alleging mistreatment, failure to notify family of changes, abuse, neglect, and care deficiencies at Genesis Senior Living.
Complaint Details
The investigation was based on substantiated complaints #111036-C, #111097-C, #111367-C, #111424-C, #112137-C, #112349-C, #111382-I, and #111925-I. Complaints involved mistreatment, failure to notify family, abuse, neglect, and care deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, failure to notify family of changes in condition, incidents of abuse and neglect, incomplete and untimely care plan updates, inadequate skin and wound care, improper use of mechanical lifts, and failure to maintain infection control practices.
Deficiencies (13)
Failure to treat residents in a dignified and respectful manner.
Failure to notify resident representatives of changes in condition.
Failure to be free from abuse and neglect, including use of profane language by staff.
Failure to timely investigate, prevent, and correct alleged abuse violations.
Failure to develop and implement comprehensive care plans reflecting current resident needs.
Failure to timely revise care plans after changes in condition or incidents such as falls.
Failure to provide scheduled showers/baths to dependent residents.
Failure to provide quality care including post-fall assessments and neurological evaluations.
Failure to provide treatment and services to prevent and heal pressure ulcers.
Failure to provide adequate supervision and safe use of devices such as mechanical lifts.
Failure to provide appropriate bowel and bladder incontinence care to prevent UTIs.
Failure to maintain resident records with identifiable information properly safeguarded.
Failure to establish and maintain an infection prevention and control program.
Report Facts
Resident census: 69
Number of complaints substantiated: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff W | Certified Nursing Assistant (CNA) | Named in abuse and profane language findings |
| Staff L | Certified Nursing Assistant (CNA) | Named in fall incident and mechanical lift misuse |
| Staff CC | Certified Nursing Assistant (CNA) | Named in incontinence care and hygiene findings |
| Staff A | Assistant Director of Nursing (ADON) | Named in wound care and notification findings |
| Staff Y | Certified Medication Technician (CMT) | Named in abuse investigation and reporting |
| Staff M | Certified Nursing Assistant (CNA) | Named in fall incident and mechanical lift misuse |
| Staff P | Regional Director of Operations | Reported on fall incident investigation |
| Staff N | OTA/Therapy Coordinator | Reported on mechanical lift training |
| Staff Q | Certified Nursing Assistant (CNA) | Named in mechanical lift use |
| Staff R | Certified Nursing Assistant (CNA) | Named in mechanical lift use |
| Staff BB | Registered Nurse (RN) | Named as nurse on call during abuse incident |
| Staff O | Registered Nurse (RN) | Named in fall incident and neurological assessment |
| Staff F | Assistant Director of Nursing (ADON) | Named in wound care and notification findings |
| Staff E | Registered Nurse | Named in wound care and notification findings |
| Staff G | Certified Nursing Assistant (CNA) | Named in oxygen removal and resident care |
| Staff H | Certified Nursing Assistant (CNA) | Named in oxygen removal and resident care |
| Staff DD | Licensed Practical Nurse (LPN) | Named in dressing change |
| Staff I | Certified Nursing Assistant (CNA) | Named in hygiene and dressing care |
| Staff T | Hospitality Aide | Named in mechanical lift and resident care |
| Staff U | Certified Nursing Assistant (CNA) | Named in mechanical lift and resident care |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 5
Date: Feb 15, 2023
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey from January 27, 2023 to February 15, 2023, including an investigation of complaints #110341-C, #110558-C, #110614-C, and #110789-C.
Complaint Details
The investigation included complaints #110341-C, #110558-C, #110614-C, and #110789-C, all of which were substantiated.
Findings
The facility was found not in compliance with CMS and CDC recommended practices for COVID-19 infection control. Deficiencies included failure to provide residents with timely access to personal funds, failure to provide two showers per week to dependent residents, improper use of personal protective equipment by staff, lack of a qualified infection preventionist working part-time at the facility, and inadequate documentation and procedures for COVID-19 testing of staff consistent with contact tracing standards.
Deficiencies (5)
Facility failed to have money accessible to residents on the same day it was requested, affecting 2 of 3 residents interviewed.
Facility failed to provide and/or offer 2 showers a week to 3 out of 3 residents reviewed.
Facility failed to provide services while adhering to accepted infection control practices; staff were observed wearing masks improperly and leaving isolation rooms with PPE on without proper disposal.
Facility failed to have a designated infection preventionist who had completed specialized training and worked at least part-time at the facility.
Facility lacked documentation to demonstrate COVID-19 testing of staff based on identification of residents diagnosed with COVID-19 consistent with current standards for contact tracing.
Report Facts
Total Residents: 61
Residents on trust representative payee list: 29
Residents positive for COVID-19: 16
Showers expected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Observed wearing mask improperly and described staff COVID-19 testing procedures |
| Staff A | Certified Nurse Aide (CNA) | Observed wearing mask improperly and described staff COVID-19 testing procedures |
| Staff C | Certified Nurse Aide (CNA) | Observed wearing mask improperly |
| Staff D | Certified Nurse Aide (CNA) | Observed wearing mask improperly |
| Staff E | Certified Nurse Aide (CNA) | Observed wearing mask improperly |
| Administrator | Provided statements regarding facility policies and infection control practices | |
| Director of Nursing | DON | Provided statements regarding infection preventionist qualifications and COVID-19 testing procedures |
| Business Office Manager | BOM | Discussed resident funds accessibility and statement distribution |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
A complaint investigation was conducted for complaints #107312, #107529, #107832, and #109360 from 2022-12-20 to 2022-12-28.
Complaint Details
Complaint investigation for complaints #107312, #107529, #107832, and #109360; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Aug 25, 2022
Visit Reason
An investigation regarding complaints 105705-C, 106272-C, 106855-C, and 107169-C, and a facility reported incident 101960-I was conducted in conjunction with a Focused Infection Control Survey on August 18 - 25, 2022.
Complaint Details
Complaints 105705-C, 106272-C, 106855-C, and 107169-C were investigated and found not substantiated. Facility reported incident 101960-I was also not substantiated.
Findings
The facility was found in compliance with CMS and CDC recommended practices. The complaints and the facility reported incident were not substantiated.
Report Facts
Total Residents: 59
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 1, 2022
Visit Reason
A second revisit was conducted via desk review of the continued non-compliance found at F 693 and F 880 during the first revisit related to the facility's annual recertification survey and investigation of multiple complaints originally conducted from October 25 to December 7, 2021.
Findings
Based on the review and acceptance of the facility's plan of correction, the facility was certified as in compliance effective March 1, 2022.
Report Facts
Complaints investigated: 11
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 2
Date: Jan 25, 2022
Visit Reason
The inspection was a revisit of the facility's annual recertification survey and investigation of multiple complaints, including complaints 97638-C, 98120-C, 98604-C, 98734-C, 99316-C, 99332-C, 99523-C, 99678-C, 99696-C, 99972-C, 100923-C, and investigations of new complaints 101282-C and 101291-C.
Complaint Details
Complaints 101282-C and 101291-C were not substantiated. The visit included investigation of multiple complaints as listed in the visit reason.
Findings
The facility failed to ensure proper placement checks of gastrostomy tubes prior to feeding, and staff did not consistently apply infection control measures including proper use of PPE and hand hygiene. Observations revealed staff not following protocols for COVID-19 testing and food handling, posing potential risks to residents. The facility reported a census of 51 residents during the inspection.
Deficiencies (2)
Failure to check placement of gastrostomy tube prior to administering enteral feeding for one resident.
Failure to ensure staff applied Personal Protective Equipment (PPE) correctly and performed hand hygiene after glove removal and changes.
Report Facts
Resident census: 51
Brief Interview for Mental Status (BIMS) score: 12
Audit duration: 4
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | agency CNA | Named in infection control deficiency; no longer works at the facility. |
| Staff B | LPN | Observed priming feeding tube and non-compliance with PPE during COVID-19 testing. |
| Staff D | Did not check for residual or tube placement prior to feeding. | |
| Director of Nursing | Director of Nursing | Provided statements on PPE expectations and ongoing audits. |
| Dietary Manager | Dietary Manager | Provided statements on hand hygiene and glove use expectations. |
| Nurse Consultant | Nurse Consultant | Reported that g-tube placement should be checked before feeding and planned staff education. |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 6
Date: Jan 6, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of multiple complaints related to resident trust fund management and care issues.
Complaint Details
Investigation of complaints #97638-C, #98120-C, #99004-C, #98743-C, #99316-C, #99332-C, #99623-C, #99670-C, #99686-C, #99702-C, and #100923-C were substantiated.
Findings
The facility was found to have multiple deficiencies related to the management of resident trust funds, failure to notify residents or representatives about missing personal funds, inadequate care planning, and failure to provide adequate skin and wound care. Several residents had cognitive impairments affecting their ability to manage funds, and the facility failed to maintain proper accounting and notification procedures.
Deficiencies (6)
Failure to maintain separate accounting for each resident's personal funds and failure to notify residents or representatives of missing funds.
Failure to provide adequate care planning and documentation for residents with cognitive impairments and skin/wound issues.
Failure to provide adequate skin and wound care, including failure to assess, document, and treat pressure ulcers and wounds.
Failure to provide adequate assistance with activities of daily living, including bathing and showering.
Failure to maintain proper medication administration and documentation.
Failure to ensure staff had current CPR certification and training.
Report Facts
Resident census: 50
Residents with cognitive impairment: 42
Residents reviewed for trust fund management: 19
Residents with BIMS scores: 15
Residents with pressure ulcers: 5
Residents with missing personal possessions: 15
Residents reviewed for care planning: 50
Residents with documented wounds: 10
Residents with documented skin assessments: 50
Residents with documented medication errors: 16
Staff CPR certifications missing: 0
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Sep 13, 2021
Visit Reason
A revisit was conducted on September 13-15, 2021 related to the investigation of complaints 96556-C, 96950-C, 96991-C, 96209-C, and 97233-C and facility reported incident 97255-I, conducted May 3 - July 27, 2021.
Complaint Details
The revisit was related to multiple complaints and a facility reported incident from May to July 2021. The facility was found not in compliance regarding restorative care provision.
Findings
The facility was found NOT IN COMPLIANCE at the time of the revisit for failure to provide necessary restorative care for two residents as evidenced by clinical record review and staff and resident interviews. The facility failed to provide restorative care services as required, and the restorative program was not fully implemented or communicated to staff.
Deficiencies (1)
Failure to provide necessary restorative care for dependent residents unable to carry out activities of daily living, including nutrition, grooming, and hygiene.
Report Facts
Resident census: 62
Dates of revisit: September 13-15, 2021
Date of last restorative program plan for Resident #13: 9/8/21
Date of last restorative program plan for Resident #14: 9/7/21
Date of plan of correction completion: 9/24/21
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 7
Date: Jul 27, 2021
Visit Reason
The inspection was conducted as an investigation of complaints 96556-C, 96950-C, 96991-C, 96209-C, and 97233-C, and a facility reported incident 97255-I, covering the period from May 3 to July 27, 2021.
Complaint Details
The visit was complaint-related, investigating multiple complaints and a reported incident. The facility failed to investigate and report allegations of missing resident property timely and had multiple care deficiencies impacting resident safety and well-being.
Findings
The facility failed to ensure allegations of missing resident property were investigated and reported timely. Deficiencies were found in providing restorative nursing programs, bathing assistance, supervision to prevent accidents, and medication administration. Several residents experienced adverse events including falls and dehydration, with one resident deceased following a fall.
Deficiencies (7)
Failed to ensure that an allegation of missing resident property was investigated and reported to the State Survey Agency within 24 hours.
Failed to provide a restorative nursing program as required.
Failed to provide bathing assistance at appropriate intervals for residents.
Failed to provide adequate supervision and assistance to prevent accidents, resulting in a resident fall with serious injury and death.
Failed to provide appropriate tube feeding management and restore eating skills.
Failed to ensure residents are free from significant medication errors.
Failed to ensure residents are free from significant medication errors related to seizure disorder treatment.
Report Facts
Census: 50
Deficiencies cited: 7
Resident weight: 115
Medication doses missed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) and former interim director of nursing | Named in findings related to restorative program, bathing assistance, and medication administration. |
| Staff B | Licensed Practical Nurse (LPN) | Involved in resident care and medication administration findings. |
| Staff F | Certified Nursing Assistant (CNA) | Mentioned in resident care and supervision findings. |
| Staff K | Occupational Therapist (OT) | Reported restorative program status. |
| Staff G | Registered Nurse (RN) | Corporate nurse providing restorative program information. |
| Staff Z | Registered and Licensed Dietician (RDLD) | Provided information on resident weight loss and feeding. |
| Staff Y | Advanced Registered Nurse Practitioner (ARNP) | Notified about seizure activity and medication administration. |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #93090 and #94206 were conducted by the Department of Inspections and Appeals from 11/4 to 11/12/2020.
Complaint Details
Complaints #93090 and #94206 were investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Both complaints were not substantiated.
Report Facts
Total residents: 45
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Sep 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaint #88226 were conducted by the Department of Inspection & Appeals.
Complaint Details
Complaint #88226 was investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #88226 was not substantiated.
Report Facts
Total residents: 52
Inspection Report
Routine
Census: 52
Deficiencies: 0
Date: Jun 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection & Appeals on 6/19/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 52
Report
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