WEBSTER CITY, IA - Southfield Wellness Community encountered significant regulatory violations during a March 2025 inspection, with inspectors documenting failures in monitoring critical lab results, delayed call light responses leading to resident incontinence, and inadequate infection control practices.
Critical Medical Test Results Left Unaddressed
Inspectors documented a particularly serious incident involving a resident with multiple cardiac conditions whose abnormal laboratory results and chest X-ray findings went unaddressed for days. The resident, identified as having heart failure, atrial fibrillation, and acute kidney failure, had blood work ordered that revealed multiple critical abnormalities.
The laboratory results showed severely elevated cardiac markers, with a brain natriuretic peptide (BNP) level of 7,919 pg/ml—more than 17 times the upper limit of normal. Elevated BNP levels indicate the heart is struggling to pump blood effectively, a critical finding in patients with known heart failure. The test results were faxed to the Advanced Registered Nurse Practitioner on a Sunday at 1:08 AM, but documentation showed no response from the provider until days later.
Additional concerning findings included impaired kidney function, with creatinine levels elevated at 1.42 (normal range 0.6-1.3) and an estimated glomerular filtration rate of 47, indicating moderate kidney impairment. The resident's albumin level was critically low at 2.6 (normal 3.4-5.0), suggesting poor nutritional status and potential liver or kidney dysfunction. Low albumin levels can contribute to fluid retention and swelling, which nurses documented the resident was experiencing.
A chest X-ray ordered the same weekend showed an enlarged heart, pulmonary vascular congestion, and fluid accumulation around the lungs—all consistent with worsening heart failure. These results were also faxed to the provider but remained unaddressed. The resident passed away four days after the initial laboratory results were obtained.
The medical significance of these delays cannot be overstated. When BNP levels reach such elevated levels in a patient with known heart failure, immediate medical intervention is typically required. This may include adjusting diuretic medications to remove excess fluid, modifying other cardiac medications, or considering hospitalization. The combination of cardiac stress, kidney impairment, and fluid overload represented a medical emergency requiring prompt physician evaluation and treatment adjustment.
According to facility policy, staff members should promptly notify the ordering physician when laboratory results fall in critical ranges or when diagnostic findings indicate acute abnormalities. The policy specifically states that if the resident's attending physician is not available, staff should contact the Medical Director or another appropriate practitioner for immediate guidance. This protocol was not followed.
When questioned, the nurse practitioner stated she was not working the weekend the results came in and didn't review them until returning to work several days later. She reported having her nurse call the facility, and staff reported the resident was "doing okay"—despite documented weight gain and significant swelling. The facility's nurse consultant confirmed multiple meetings had been held with the provider regarding timeliness of addressing concerns.
Prolonged Call Light Response Times Result in Dignity Issues
Multiple residents reported waiting 30 minutes to over an hour for staff to respond to call lights, leading to embarrassing incidents of incontinence. Four residents documented similar patterns of delayed assistance, with electronic call light records confirming response times far exceeding the facility's 15-minute standard.
One resident who required two-person assistance for transfers and toileting reported waiting 30 minutes to an hour regularly, stating the delays made him "feel low on the priority list." Call light records showed this resident experienced response times ranging from 18 to 65 minutes on multiple occasions throughout February 2025.
Another resident with multiple sclerosis who required total assistance with toileting described a particularly distressing incident where she waited two hours sitting on the toilet. Staff had assisted her onto the toilet but then left, saying they would return shortly. When they didn't return, she activated her call light. Someone responded briefly but said they needed another person to help and would be back. The resident remained partially clothed, sitting on the toilet for two hours before receiving assistance. She reported her legs and buttocks hurt after the prolonged wait. Electronic records for this resident showed 12 instances over 30 days where call light response exceeded 20 minutes, with the longest wait being 47 minutes.
From a medical perspective, prolonged sitting on toilets presents multiple risks. Patients with mobility impairments can develop pressure injuries on the buttocks and backs of legs from extended periods in one position, particularly on hard surfaces. The circulatory system can be compromised, leading to numbness, nerve compression, and decreased blood flow to the lower extremities. For individuals with neurological conditions like multiple sclerosis, these risks are amplified due to existing circulation and sensation issues.
A newly admitted resident reported becoming incontinent of bowel movements multiple times due to insufficient staffing, stating it made her feel "like a baby." This resident's call light records showed 19 instances over three weeks where response times exceeded 15 minutes, including one wait of 90 minutes. She also reported requesting pain medication (Tylenol) at 1:15 AM and not receiving it until 7:30 AM the following morning.
A fourth resident reported waiting up to 30 minutes for call light responses and experiencing bowel incontinence while waiting for assistance. This resident stated he timed the responses using his phone. Records confirmed 52 instances over approximately one month where his call light response exceeded 15 minutes, with waits ranging from 20 minutes to over an hour.
The psychological impact of incontinence on nursing home residents is well-documented in healthcare literature. Adults who lose bladder or bowel control due to inability to access timely assistance often experience shame, loss of dignity, and decreased self-worth. This can lead to depression, social withdrawal, and reluctance to request help in the future—creating a cycle that further compromises care quality and resident wellbeing.
Inadequate staffing patterns contribute to delayed call light responses. Residents reported observing only two staff members—one nurse and one certified nursing assistant—covering three hallways during some shifts. Industry standards suggest staffing ratios should be adequate to meet resident needs promptly, particularly for facilities serving individuals requiring substantial to total assistance with activities of daily living.
The facility's Call Light Policy, revised in September 2023, requires staff to answer call lights in a timely manner and respond to requests promptly. The policy acknowledges that if immediate assistance cannot be provided and the resident doesn't have an emergent need, staff may inform the resident someone will return shortly. However, the policy provides no specific timeframe for "timely" or "shortly," creating ambiguity in expectations. The Administrator confirmed the facility's expectation was 15-minute response times, though this standard was not consistently met.
Untrained Staff Performed Medical Procedures
Inspectors identified an incident where a certified nursing assistant (CNA) performed a bladder irrigation procedure—a task requiring nursing licensure—because an agency nurse reported not knowing how to complete the treatment. The resident required daily antibiotic bladder irrigations through a suprapubic catheter (a tube surgically placed through the abdomen directly into the bladder) to prevent urinary tract infections.
Bladder irrigations require sterile technique and specialized training to prevent introducing bacteria into the bladder, which could cause serious infections. The procedure involves instilling antibiotic solution into the bladder through the catheter, clamping the catheter for a specified period to allow the medication to work, then draining the solution. Improper technique can lead to catheter damage, tissue injury, or life-threatening infections—particularly concerning for patients with neurogenic bladder conditions who already face elevated infection risks.
The CNA acknowledged performing the procedure on February 22, 2025, stating the agency nurse asked her to complete the task after admitting unfamiliarity with the procedure. The CNA reported the resident coached her through the steps. "I admit I did this, that I didn't have the training to do this, and shouldn't have done the treatment," the CNA told inspectors. She confirmed awareness the task fell outside her scope of practice and that a licensed nurse should have performed it.
Both the Director of Nursing and Administrator stated they were unaware of the incident until informed by inspectors, contradicting the CNA's claim that she left a note and discussed the situation with the Director of Nursing. The CNA job description, revised in December 2014, limits duties to activities of daily living assistance and does not include invasive procedures or medication administration.
The use of agency nurses who lack familiarity with specialized resident needs presents significant safety risks in long-term care settings. Facilities must ensure all nursing staff—whether permanent or temporary—receive adequate orientation to complex resident care needs and have demonstrated competency before working independently. The incident raised questions about supervision practices, particularly during evening and night shifts when administrative oversight may be reduced.
Additional Issues Identified
Infection control and antibiotic monitoring practices fell short of regulatory requirements. While the facility's Antibiotic Stewardship Policy outlined comprehensive tracking requirements, inspectors found no evidence the Infection Preventionist monitored when antibiotics started, tracked laboratory data, or evaluated treated infections against evidence-based criteria. The facility provided only a color-coded map showing infection locations but could not document systematic monitoring of three residents receiving antibiotics for urinary tract infections and MRSA during the inspection period.
Effective antibiotic stewardship programs are essential for preventing antibiotic resistance and ensuring infections receive appropriate treatment. Programs should track which antibiotics are prescribed, monitor whether infections resolve, and identify patterns that might indicate resistant organisms. Without this systematic oversight, facilities risk continued use of ineffective antibiotics, development of resistant infections, and missed opportunities to identify care practice improvements.
Quality assurance processes failed to address recurring violations identified in multiple surveys over the previous year. Seven areas of concern cited during this inspection had been identified in previous surveys, including issues with comprehensive care planning, activity of daily living care for dependent residents, quality of care, accident hazards, dialysis care, sufficient nursing staff, and quality assurance programming itself. The Administrator acknowledged repeated concerns and described ongoing efforts to improve, including culture change initiatives, accountability measures for staff, and corporate assignment of a Regional Nurse Consultant for support.
Care planning deficiencies affected multiple residents. Inspectors found care plans that failed to address residents' comprehensive needs, lacked individualization, or didn't reflect current conditions. Proper care planning requires interdisciplinary assessment, individualized goal setting, and regular evaluation of whether interventions effectively address resident needs. Care plans serve as roadmaps for consistent care delivery across shifts and must be detailed enough that any staff member can understand and implement the prescribed interventions.
Dialysis care concerns emerged during the inspection, though specific details were not elaborated in the available documentation. Dialysis patients in nursing homes require specialized monitoring due to fluid balance management, vascular access care, medication adjustments, and coordination with dialysis centers. Any deficiencies in this area pose serious risks given the medically complex nature of this population.
The facility reported a census of 54 residents at the time of the inspection on March 3, 2025. The inspection findings reflect systemic issues requiring comprehensive corrective action across multiple operational areas, from clinical oversight and staffing adequacy to staff training and quality improvement processes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southfield Wellness Community from 2025-03-03 including all violations, facility responses, and corrective action plans.
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