Inspection Reports for
Greater Southside Health and Rehabilitation

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.

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.

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.

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.

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.

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.

Complaint #128140-C was substantiated, resulting in deficiencies related to quality of care concerning abnormal vital signs monitoring and reporting.

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.

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.

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.

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.

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.

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.

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.

The complaint investigation was substantiated. The Iowa Department of Inspections, Appeals, and Licensing staff determined an Immediate Jeopardy situation existed at the facility due to a resident leaving the facility without staff knowledge. The facility took corrective actions including installing temporary alarms, staff education, and conducting door alarm drills.

The investigation found that the facility failed to properly secure exit doors and adequately supervise residents to prevent accidents, resulting in a resident leaving the facility without staff knowledge. The facility implemented temporary alarms and staff education to address the deficiencies and prevent future incidents.

Complaint #121702-C was substantiated.

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.

Complaint #120390-C was substantiated based on findings including failure to notify family of change in condition and unsafe transport practices.

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.

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.

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.

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.

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.

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.

Complaint #1113653-C was substantiated. The investigation included observations, interviews, and record reviews related to resident rights violations and other care concerns.

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.

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.

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.

The investigation included complaints #110341-C, #110558-C, #110614-C, and #110789-C, all of which were substantiated.

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.

Complaints 101282-C and 101291-C were not substantiated. The visit included investigation of multiple complaints as listed in the visit reason.

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.

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.

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.

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.

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.

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.

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.