Inspection Reports for
Greater Southside Health and Rehabilitation

All deficiencies were corrected and the facility is in substantial compliance effective June 12, 2026.

The facility will be certified in compliance effective April 29, 2026, based on acceptance of the Plan of Correction.

The facility failed to accurately reconcile hospital discharge orders and notify medical providers of follow-up needs for three residents, resulting in significant harm including a resident experiencing 14.5 months without diabetic treatment and hospitalization for life-threatening blood sugar levels. Additional failures included medication errors and inadequate monitoring of residents' conditions.

Complaints #3006010-C and #3008034-C resulted in a deficiency.

The facility failed to accurately reconcile hospital discharge orders for three of four residents reviewed, resulting in significant medication errors and harm. A plan of correction was implemented including staff education, competency validation, and monitoring to prevent recurrence.

The facility was found noncompliant with multiple regulatory requirements including failure to timely report allegations of abuse, update care plans for smoking/vaping, ensure free of accident hazards and adequate supervision, provide proper respiratory care, and prevent significant medication errors. The facility submitted corrective actions and monitoring plans for each deficiency.

The facility failed to report an allegation of abuse involving Resident #2 to the Iowa Department of Inspections, Appeals and Licensing within the required two-hour timeframe. The resident exhibited agitation and accused staff of abuse, but the facility delayed reporting the incident until approximately 13 hours later.

All deficiencies were corrected and the facility is in substantial compliance effective November 14, 2025.

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 facility failed to report allegations of abuse to the Department of Inspections, Appeals and Licensing (DIAL) in a timely manner for 2 of 3 residents reviewed. Additionally, there was a verbal altercation involving a resident and a Licensed Practical Nurse (LPN) that was not reported promptly. The facility acknowledged poor services and educated staff on reporting abuse.

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.

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.

Investigation of Complaint #129613-C; facility found in compliance.

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.

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.

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.

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.

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.

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.

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 facility failed to protect Resident #3 from financial abuse by a Certified Nurses Aide who accessed the resident's locked drawer and took $55. The employee was terminated for this violation.

Complaints 125210-C and #125541-C were investigated and found not substantiated.

All deficiencies were corrected and the facility is in substantial compliance effective November 16, 2024. Complaints 125210-C and #125541-C were not substantiated.

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 facility failed to identify and reduce the risk of injury from excessively hot water in the upstairs shower room, resulting in Resident #2 sustaining a 2nd degree burn. Water temperature was measured at 145.2 degrees Fahrenheit, exceeding safe limits. The facility continued to provide showers in the hazardous shower room until it was taken out of order.

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.

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.

The facility failed to provide adequate assessment and intervention for 4 residents, resulting in harm to one resident who required emergent transfer to a higher level of care. Additional failures included not responding to wound vac alarms, not ensuring oxygen therapy was administered as ordered, and not following physician orders for oxygen levels.

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.

The facility failed to secure exit doors, as staff used a rock to prop open a door to re-enter the building. Resident #1, who had a history of wandering and elopement risk, left the facility without staff knowledge and was missing for over a day. The resident was found outside and had sought emergency medical care. Staff interviews and records showed inconsistent use and monitoring of wander guards and inadequate supervision during a busy event evening.

No concerns were observed and all deficiencies were corrected; the facility will be certified in compliance effective July 23, 2024.

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.

The facility failed to provide appropriate therapeutic diets to residents #4 and #26, serving foods that posed choking and aspiration risks, such as unmodified bread products and Cheeto Puffs on pureed diets. The kitchen also failed to document substitutions and did not consistently follow diet orders, resulting in unsafe meal service practices.

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.

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.

The facility failed to properly assess and intervene for two residents with condition changes, including inadequate monitoring and documentation of vital signs, wounds, and swelling. Resident #3 developed worsening pressure ulcers and edema, was sent to the hospital, and subsequently died from sepsis. Resident #2 experienced respiratory decline and was hospitalized with acute respiratory failure. No assessments were completed timely or adequately for both residents during their decline.

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.

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 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.

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 facility failed to administer prescribed pain medications to four residents for prolonged periods, resulting in immediate jeopardy that was later abated. Additionally, the facility failed to run a timely criminal background check and obtain a 'may work' letter for a registered nurse before employment.

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 facility failed to ensure proper wound care for Resident #3, resulting in a Stage 4 pressure ulcer with bone infection and prolonged hospitalization. Additionally, the facility failed to provide safe mechanical lift transfers for five residents, including a fall from a Hoyer lift causing injury. Multiple staff failed to follow proper protocols, including use of appropriate slings, two-person transfers, and notification of family after incidents.

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.

Complaint investigation for complaints #107312, #107529, #107832, and #109360; facility found in substantial compliance.

The facility was found to be in substantial compliance.

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.

The facility was found in compliance with CMS and CDC recommended practices. The complaints and the facility reported incident were not substantiated.

Based on the review and acceptance of the facility's plan of correction, the facility was certified as in compliance effective March 1, 2022.

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 facility failed to provide and document required nursing services including medication administration, wound care, and pain management. Resident #101 experienced multiple hospitalizations and passed away after wounds with maggots were found. Resident #53 had an unassessed and untreated pressure ulcer. Resident #50 had unmanaged pain and incomplete care plans. Resident #16 did not receive ordered COVID-19 related medications.

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.

The facility failed to provide adequate supervision and assistance to prevent hazards for two residents, resulting in multiple falls, serious injuries, and one resident's death. The facility also failed to implement proper post-fall assessments and timely communication with family members.

Complaints #93090 and #94206 were investigated and found to be not substantiated.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Both complaints were not substantiated.

Complaint #88226 was investigated and found not substantiated.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #88226 was not substantiated.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.