Southfield Wellness Community

F-F684 for additional information regarding Resident #55. The facility reported a census of 54 residents.

Findings include:

Resident #55's MDS (Minimum Data Set) assessment dated [DATE REDACTED] identified a BIMS (Brief Interview for Mental Status) score of 11, indicating moderately impaired cognition. Resident #55 required substantial to maximal assistance with bed mobility and all transfers. The MDS included diagnosis of heart failure (inability for the heart to pump blood), hypertension (high blood pressure), atrial fibrillation (irregular heart beat), diabetes mellitus and acute kidney failure. The MDS documented Resident #55 received diuretic medication

during the lookback period.

A Progress Note dated [DATE REDACTED] documented the ARNP (Advanced Registered Nurse Practitioner) saw Resident #55 and ordered the following:

a. Obtain the following labs and x ray

i. CMP (complete metabolic panel)

ii. BNP (brain natriuretic peptide)

iii. CBC with differential (complete blood count)

iv. portable chest x ray.

b. Resident #55 may benefit from evaluation by Hospice.

A Progress Note dated [DATE REDACTED] (Sunday) at 1:08 AM documented the facility received Resident #55's lab results for the CBC with differential, CMP and BNP. The progress note documented the following abnormalities:

a. Auto hematology

- Auto monocyte percent - 14.8(H) (expected equal to or under 12, may indicate infection),

- RBC (Red blood cells) - 3.87(L) (expected 4.6 - 6.20),

- Hemoglobin (Hgb) - 9.6 (L) (expected 13.5 - 18), Hematocrit (Hct) - 32.6(L) (expected 37 - 47)

- MCH (a measure of the average Hgb in the RBCs) - 24.8(L) (expected 29 - 35),

- RDW (measures the size of the RBC) - 20.2(H) (expected 11.5 - 14.5).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0713 b. General Chemistry

Level of Harm - Minimal harm or - Glucose - 151(H) (expected 70 - 99) potential for actual harm - BUN (measures kidney function) - 35(H) (expected ,d+[DATE REDACTED]) Residents Affected - Few - Creatinine (measures kidney function) - 1.42(H) (expected 0.6 - 1.3)

- BUN/Creat ratio - 25(H) (expected 10 - 20)

- eGFR CKD EPI (measure kidney disease stages) - 47(L) (expected greater than 90, 47 indicated moderate impairment)

- AST (measures liver function) - 9(L) (expected ,d+[DATE REDACTED]),

- Total protein - 6.3(L) (expected 6.4 - 8.2)

- Albumin (measures the liver and kidney function) - 2.6(L) (expected 3.4 - 5)

- Globulin (measures kidney and liver function) - 3.7(H) (expected 2.3 - 3.5)

- A/G ratio (measures nutritional status, immune function, and overall health) - 0.7(L) (expected 1.1 - 2).

c. Cardiac Isoenzymes (checks heart function)

- NT proBNP (checks heart function) - 7919(H) (expected ,d+[DATE REDACTED]).

The Progress Note on [DATE REDACTED] at 1:08 AM reflected Resident #55 had a BNP result of 7,919 pg/ml (picograms per milliliter), with a reference range of 0 450. (A high BNP level may indicate heart failure, kidney failure, pulmonary embolism or other conditions).The progress note documented they faxed the lab results to the ARNP for review.

A Progress Note dated [DATE REDACTED] at 2:29 PM documented Resident #55 continued to have increased weight gain with pitting edema noted to hands, arms and back.

A Progress Note dated [DATE REDACTED] documented Resident #55's abnormal chest x ray results. The chest x ray impression showed the cardiac silhouette was enlarged, mild pulmonary vascular congestion and small bilateral pleural effusions with bibasilar atelectasis and or consolidation. The note documented the abnormal results were faxed to the ARNP for review.

Review of the clinical record lacked documentation that the ARNP addressed the abnormal lab results faxed

on [DATE REDACTED]. The progress notes lacked any follow up or other means of communication with the ARNP regarding the abnormal lab results.

Review of the Progress Notes lacked documentation the ARNP addressed the abnormal chest x ray results faxed on [DATE REDACTED]. The progress notes lacked any follow up or other means of communication with the ARNP regarding the abnormal chest x ray results.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0713 The Progress Note dated [DATE REDACTED] at 1:45 PM revealed Resident #55 expired at 11:07 AM.

Level of Harm - Minimal harm or Review of Resident #55's chest x ray results dated [DATE REDACTED] revealed the ARNP signed/noted the x ray on potential for actual harm [DATE REDACTED] after Resident #55 has expired.

Residents Affected - Few A communication form titled Reminders provided by the facility on [DATE REDACTED] for Resident #55 revealed on [DATE REDACTED] at 1:49 PM the ARNP reviewed the abnormal lab results and directed her nurse to call the facility with the results and inquired about Resident #55's shortness of breath. The form documented the ARNP's nurse spoke to a facility nurse on [DATE REDACTED] at 4:52 PM. The form documented the facility nurse reported Resident #55 lost 2 lbs. and was doing okay. The form lacked additional direction or Physician orders regarding the abnormal lab results.

On [DATE REDACTED] at 5:50 PM, Staff A, Nurse Consultant, verified the facility faxed the lab results on [DATE REDACTED] (Sunday) and the Provider didn't review them until [DATE REDACTED]. Staff A verified a lack of follow up regarding the lab results. In addition, Staff A verified the Provider didn't follow-up or review Resident #55's chest x ray results until [DATE REDACTED]. The Nurse Consultant reported the facility was working with the ARNP on her timeliness of addressing concerns and had multiple meetings to discuss this.

On [DATE REDACTED] at 11:27 AM, the ARNP reported she didn't provide coverage over the weekend ([DATE REDACTED]) and that a hospitalist covered for her. The ARNP reported she not being in work status on ,d+[DATE REDACTED] and , d+[DATE REDACTED]. She said she returned to work status on ,d+[DATE REDACTED] and reviewed the labs then. She said she had her nurse call the facility to follow up on Resident #55 and the facility nurse reported him as doing ok. When asked if he had a BNP lab completed prior, she reported Resident #55 as a new patient for her starting in [DATE REDACTED]. She explained she didn't have a baseline BNP. When asked about the chest x ray results, the ARNP reported she didn't review the results the week of [DATE REDACTED]. She reported she looked for the chest x ray results

in the chart last night ([DATE REDACTED]) and the next morning ([DATE REDACTED]), but she couldn't locate the results. She said usually an outside provider sent a copy of the results and then someone scanned the results in the chart.

She said she didn't work [DATE REDACTED] or [DATE REDACTED]. She said the following week she had clinic day on Thursday, [DATE REDACTED] and her clinic folder would have the fax with the chest x ray results inside. She reported she noted

the chest x ray report on that day which was consistent with the date on the chest x ray form in the facility chart. She reported she didn't know of the facility's policy but if the patient's condition changed or if they had

a concern, the facility generally reached out to her.

On [DATE REDACTED] at 12:53 PM, Staff A reported she expected the staff to follow up on the lab and chest x ray results with another means of communication if the Provider didn't respond in a timely manner. Staff A reported critical lab values should be reported immediately and non critical abnormal labs reported within 24 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0713 A facility policy titled Laboratory/Diagnostic Value Reporting revised [DATE REDACTED] directed to promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist of laboratory, radiology Level of Harm - Minimal harm or and other diagnostic services with results that are in a critical reference range. The policy directed the facility potential for actual harm would promptly notify the resident's attending physician, when STAT (immediate) laboratory results are available or when lab results are clinically considered critical. When the laboratory received any critical Residents Affected - Few laboratory result or detected by the nursing staff, the result would be communicated to the physician/ordering clinician promptly. If the resident didn't have their attending physician available, then they should contact the Medical Director or appropriate facility practitioner for notifications and orders. Radiology reports with findings conclusive of acute abnormalities or significant changes in conditions would be communicated to the resident's attending physician promptly. If the resident's attending physician was not available, the Medical Director or appropriate facility practitioner would be contacted for notifications or orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44512

Residents Affected - Few Based on observation, clinical record review, resident, and staff interviews, the facility staff failed to consistently answer call lights within a reasonable amount of time (15 minutes). Residents reported having to wait thirty to forty five minutes for someone to answer their call light numerous times during the week. The facility reported a census of 54 residents.

Findings include:

1. Resident #46's Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #46 required substantial assistance of 2 staff for transfers and toileting. The MDS included a diagnosis of hemiplegia (paralysis of one side of the body).

During an interview on 2/24/25 at 12:41 PM, Resident #46 stated the staff took a long time to answer their call light. Observed Resident #46 in a wheelchair, with his left leg and left arm secured to the wheelchair arm rest. Resident #46 stated it took 30 minutes to an hour in the afternoon and evening shifts. Resident #46 stated, he didn't have accidents but squirmed, it made him feel low on the priority list. Resident #46 stated when his call light pendant broke, it didn't get replaced, he couldn't reach the call light and had to yell for help.

A call light response document for Resident #46 revealed:

a. On 2/18/25 at 7:36 AM a call response time of 37 minutes.

b. On 2/29/25 at 6:04 PM a call response time of 18 minutes.

c. On 2/19/25 at 6:44 PM a call response time of 37 minutes.

d. On 2/20/25 at 12:10 PM a call response time of 32 minutes.

e. On 2/21/25 at 11:48 AM a call response of 1 hour and 5 minutes.

f. On 2/25/25 at 6:39 AM using pendent, a call response time of 36 minutes.

48886

2. Resident #6's Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #6 required total assistance from staff toileting hygiene and lower body dressing. Resident #6 used a wheelchair for mobility. The MDS included diagnoses of progressive neurological conditions, diabetes mellitus and multiple sclerosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview 2/24/25 at 1:16 PM, Resident #6 stated over the past weekend she waited for 2 hours in

the bathroom for staff to help her. Resident #6 stated she needed help getting dressed and in the bathroom Level of Harm - Minimal harm or for toileting hygiene. Resident #6 stated she had times at night when the facility only had 1 nurse and 1 CNA potential for actual harm for the whole building, then someone would come in later sometimes to help. The facility used agency staff sometimes and did the past weekend. Resident #6 described herself as partially clothed, while she sat on Residents Affected - Few the toilet for 2 hours waiting for someone to help. She reported her legs and butt hurt after sitting on the toilet for 2 hours. Resident #6 reported it as frustrating. They came in to help her get on the toilet, and then left, saying they would be back in a few minutes, but they didn't come back in a few minutes. Resident #6 said

after waiting several minutes for staff to return to help her off the toilet and help with toileting hygiene, she turned her call light on again. Someone came back, saying they needed another person and would be back again. Resident #6 stated she waited for 2 hours for someone to come back to assist her off the toilet, with toileting hygiene, and lower body dressing. Resident #6 stated she had other times she waited longer than 15 minutes for a call light response.

The facility call light report for the past 30 days for Resident #6, from 1/29/25 to 2/25/25, listed 12 instances where Resident #6 waited longer than 20 minutes for a call light response:

a. 1/30/25 at 7:18 PM, 20:54 minutes

b. 1/31/25 at 9:34 AM, 21:58 minutes

c. 1/31/25 at 1:26 PM, 32:01 minutes

d. 2/4/25 at 8:33 AM, 39:29 minutes

e. 2/7/25 at 5:07 PM, 43:08 minutes

f. 2/8/25 at 10:39 AM, 34:11 minutes

g. 2/9/25 at 7:41 AM, 30:03 minutes

h. 2/13/25 at 12:41 PM, 30:20 minutes

i. 2/16/25 at 11:05 AM, 26:18 minutes

j. 2/17/25 at 12:44 PM, 20:20 minutes

k. 2/24/25 at 8:21 AM, 47:21 minutes

l. 2/25/25 at 7:21 PM, 24:57 minutes

46875

3. Resident #24's Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.

Resident #24's Clinical Census listed an admitted [DATE REDACTED], into Room A7 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 2/24/25 at 11:22 AM, Resident #24 said she became incontinent of BM (bowel movement) a couple of times since she admitted to the facility, due to not having enough staff. She reported she felt like a baby Level of Harm - Minimal harm or when she became incontinent. She said the staff might answer her call light in 5 minutes but then took 40 potential for actual harm minutes to come back and help her. She reported last night (2/23/25) she put her call light on at 1:15 AM and asked for some Tylenol and she didn't get it until that morning around 7:30 AM. She reported the staff are Residents Affected - Few nice but they didn't have enough people. She described 2 staff members for 3 hallways as not enough.

A facility form titled Past Events for dates 2/6/25 to 2/26/25 for Room A 7 reflected the following call light elapsed times greater than 15 minutes:

a. 2/6/25 - 8:48 PM = 1 hour 30 minutes

b. 2/7/25 - 10:15 PM = 25 minutes

c. 2/8/25 8:44 PM = 23 minutes

d. 2/10/25 - 8:42 AM = 25 minutes

e. 2/12/25 - 4:44 AM = 20 minutes

f. 2/14/25 - 7:33 AM = 30 minutes

g. 2/15/25 - 7:43 AM = 46 minutes

h. 2/15/25 - 9:15 PM = 20 minutes

i. 2/16/25 - 10:02 PM = 21 minutes

j. 2/18/25 - 6:56 AM = 26 minutes

k. 2/18/25 - 7:57 AM = 28 minutes

l. 2/19/25 - 8:32 AM = 25 minutes

m. 2/20/25 - 8:39 AM = 20 minutes

n. 2/21/25 - 7:16 AM = 28 minutes

o. 2/21/25 - 9:06 AM = 24 minutes

p. 2/22/25 - 7:58 AM = 29 minutes

q. 2/23/25 - 7:36 AM = 20 minutes

r. 2/24/25 - 1:31 AM = 27 minutes

s. 2/24/25 - 7:43 AM = 34 minutes

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 4. dated 2/3/25 Resident #13 identified a BIMS score of 15, indicating intact cognition.

Level of Harm - Minimal harm or The Clinical Census revealed Resident #13 was admitted to the facility on [DATE REDACTED] and resided in Room B45 potential for actual harm 1.

Residents Affected - Few On 2/24/25 1:33 PM, Resident #13 said he can wait up to 30 minutes for his call light to be answered. He explained he pooped his pants before waiting for someone to answer his call light, he added it made him feel embarrassed. He reported he used his phone to time the call light response.

A facility form titled Past Events for dates 1/25/25 to 2/26/25 for Room B 45 revealed the following call light elapsed times greater than 15 minutes:

a. 1/27/25 - 9:48 PM = 26 minutes

b. 1/29/25 - 9:43 AM = 28 minutes

c. 1/29/25 - 12:49 PM = 24 minutes

d. 1/31/25 - 5:44 PM = 25 minutes

e. 1/31/25 - 6:46 PM = 58 minutes

f. 2/1/25 - 11:11 AM = 25 minutes

g. 2/1/25 - 5:25 PM = 29 minutes

h. 2/1/25 - 6:42 PM = 27 minutes

i. 2/4/25 - 1:12 AM = 23 minutes

j. 2/4/25 - 5:37 PM = 23 minutes

k. 2/5/25 - 9:05 PM = 1 hour 4 minutes

l. 2/6/25 - 4:20 PM = 21 minutes

m. 2/6/25 - 5:42 PM = 26 minutes

n. 2/6/25 - 6:24 PM = 27 minutes

o. 2/7/25 - 11:08 AM = 39 minutes

p. 2/7/25 - 10:14 PM = 27 minutes

q. 2/8/25 - 12:09 AM = 21 minutes

r. 2/8/25 - 2:57 PM = 20 minutes

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 s. 2/8/25 - 6:24 PM = 20 minutes

Level of Harm - Minimal harm or t. 2/8/25 - 7:08 PM = 45 minutes potential for actual harm u. 2/10/25 - 7:14 PM = 33 minutes Residents Affected - Few v. 2/12/25 - 12:37 PM = 42 minutes

w. 2/12/25 - 4:32 PM = 21 minutes

x. 2/12/25 - 9:14 PM = 30 minutes

y. 2/13/25 - 11:42 AM = 21 minutes

z. 2/13/25 - 5:06 PM = 22 minutes

aa. 2/14/25 - 1:49 PM = 20 minutes

bb. 2/15/25 - 8:14 AM = 39 minutes

cc. 2/15/25 - 12:17 PM = 31 minutes

dd. 2/16/25 - 7:56 PM = 28 minutes

ee. 2/19/25 - 9:59 AM = 27 minutes

ff. 2/19/25 - 4:22 PM = 22 minutes

gg. 2/19/25 - 7:54 PM = 32 minutes

hh. 2/20/25 - 8:23 AM = 37 minutes

ii. 2/21/25 - 8:40 PM = 21 minutes

jj. 2/22/25 - 7:52 PM = 21 minutes

kk. 2/24/25 - 7:15 PM = 26 minutes

On 2/26/25 at 11:30 AM, Staff F, CNA (certified nursing assistant), reported Resident #13 had times when he requested to go to the bathroom, but the staff were busy and not available to take him. Staff F confirmed Resident #13 had incontinence of bowel and bladder while waiting for staff to assist him.

On 2/26/25 at 10:15 AM, the Administrator reported she expected the staff to answer call lights within 15 minutes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 The facility policy titled Call Light Policy revised September 2023 instructed to ensure a prompt response to a resident's call for assistance and to ensure the call system properly worked. The policy included the facility Level of Harm - Minimal harm or should answer call lights in a timely manner and when answering a call light, respond to the request. If they potential for actual harm couldn't provide immediate assistance and the resident didn't have an emergent need, they can turn the call light off and inform the resident a staff member would be back to assist them shortly. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48886

Residents Affected - Few Based on clinical record review, resident and staff interviews and policy review, the facility failed to adequately trained staff to perform a treatment for 1 of 1 resident reviewed (Resident #6). The facility failed to have a nurse flush Resident #6's catheter as ordered. Instead of the nurse, a Certified Nursing Aide (CNA)

the irrigated/flushed Resident #6's catheter. The facility reported a census of 54 residents.

Findings include:

Resident #6's Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of progressive neurological conditions, diabetes mellitus, neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage to the nerves that control it), and multiple sclerosis. The MDS identified the resident had an indwelling catheter.

The Care Plan Focus with a target date of 3/11/25, indicated Resident #6 required the use of a suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen directly into the bladder) related to a neurogenic bladder. The Interventions instructed to irrigate/flush Resident #6's catheter as ordered.

During an interview 2/24/25 at 1:18 PM, Resident #6 stated on the previous Saturday (2/22/25), the nurse didn't know how to flush her catheter. The nurse said she did, but then said she didn't. Resident #6 stated

she flushed her catheter herself with the help of a CNA.

During an interview 2/27/25 at 1:26 PM, Resident #6 stated an agency nurse worked the Saturday night of 2/22/25. The agency nurse said she didn't know how to flush the catheter. Resident #6 reported the flush as

an antibiotic flush, that the agency nurse didn't know how to do. Resident #6 stated Staff E, CNA, and her did

the flush together. Resident #6 reported the flush as her gentamicin bladder irrigation flush. Resident #6 stated they didn't have complications. In addition, Staff E wore a gown and gloves.

Resident #6's Order Details directed to irrigate the bladder with gentamicin bladder irrigation (a procedure that involved instilling a solution of the antibiotic gentamicin directly into the bladder to treat or prevent urinary tract infections) 240 milligrams (mg) / 500 milliliters (ml) normal saline, one time a day for infection prevention. The Order instructed to instill 30 ml into bladder daily, clamp for 30 minutes then drain. The order listed a start date of 10/17/24 and scheduled for Resident #6's hour of sleep (HS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 During an interview 2/27/25 at 2:15 PM, Staff E stated she worked at the facility for 6 years, full time hours as

a CNA. She explained she didn't train for any other job duty other than a CNA. She worked primarily in the Level of Harm - Minimal harm or back hall, where Resident #6 resides. Staff E stated she worked the last Saturday, 2/22/25, on the 2:00 PM potential for actual harm to 10:00 PM shift with an agency nurse that night. That night, around 9:15 PM, Staff E went and told the agency nurse that Resident #6 was ready for her flush. The agency nurse said what is that? Staff E stated Residents Affected - Few she explained the flush to the agency nurse and the agency nurse said they didn't know what they were doing. The agency nurse thought the CNA's could do more than what they could and asked throughout the night for the CNA's help. Staff E stated she told the agency nurse CNA's couldn't do certain cares, including

the flush. The agency nurse told Staff E to do the flush for Resident #6. Staff E stated she went into Resident #6's room by herself, the agency nurse didn't go with her at all, and she performed Resident #6's flush/irrigation, with Resident #6 telling her what to do. Staff E stated she admits she did this, that she didn't have the training to do this, and shouldn't done the treatment. She stated Resident #6 walked her through what to do. Staff E stated she clamped where Resident #6 told her to clamp, unhooked the bag, put the flush/antibiotic fluid in, unclamped and pushed the flush in and then put the resident's catheter back together. Staff E stated she felt it went okay and Resident #6 told her it went okay. Staff E stated she wore a gown and gloves. Staff E stated she left a note for the Director of Nursing (DON) about what she did. Staff E stated the DON talked to her and told her not to do it again, she said nothing else happened as far as discipline. Staff E stated an awareness she is not trained or qualified to perform this task, a licensed nurse should have performed it.

During an interview 2/27/25 at 2:35 PM, the DON stated she didn't know anything about Staff E performing a flush/irrigation with Resident #6 over the weekend. She added Staff E didn't leave her a note and she didn't talk to Staff E about the situation. The DON stated a CNA didn't have training to perform this type of care and Staff E knew she shouldn't perform the care, as it wasn't within her scope of practice. The DON stated they did have an agency nurse work the past Saturday night, 2/22/25. The Administrator was present during the

interview and stated she didn't know about this taking place either. The DON and the Administrator stated

they expected the staff to not perform cares beyond their scope of practice and training.

A review of the facility CNA job description document, revised December 2014, documented in the general summary, a CNA helps with activities of daily living and effectively implements, communicates and documents resident care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 46875 potential for actual harm Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past Residents Affected - Many surveys, and staff interviews, the facility failed to correct their own deficiencies for 7 of 12 areas of concern.

The facility reported a census of 54 residents.

Findings include:

The facility QAPI Plan reviewed 1/14/24 defined the mission as to provide resident centered healthcare services, excellence in clinical care, and to promote care giver engagement and empowerment to better serve the resident, family and the community. The guiding principles consisted of the following:

QAPI has a prominent role in our management and board functions on par with monitoring reimbursement and maximizing revenue.

QAPI outcomes are directly related to the quality of care and the quality of life of the residents.

- The organization uses QAPI to make decisions and guide the day to day operations.

QAPI included all employees, all departments and all services provided.

The QAPI program focuses on our organization's systems and processes and the facility strives to continually identify and make changes to the systems/processes in order to improve outcomes.

The organization makes QAPI decisions based on data gathered from the input and experience of the caregivers, residents, health care practitioners, families, and other stakeholders.

The organization sets goals for performance and measures progress towards those goals.

The organization supports performance improvement by encouraging the employees to support each other as well as to be accountable for their own professional performance and practice.

The organization maintains a culture that encourages, rather than punishes, employees who identify errors or system breakdowns.

The survey identified the following concerns duirng the current survey, that were also cited at surveys in the past year:

a. Development/Implement comprehensive Care Plan

b. ADL (activity of daily living) care provided for dependent residents

c. Quality of care

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 d. Free of accident hazards/supervision/devices

Level of Harm - Minimal harm or e. Dialysis potential for actual harm f. Sufficient Nursing Staff Residents Affected - Many g. QAPI program/plan, disclosure/good faith attempt

On 3/3/25 at 11:02 AM, the Administrator acknowledged the repeated concerns and reported she thought the facility had a better plan in place to address the concerns. The Administrator voiced the importance of having

the right people in the right position and that several administration nurses are no longer in the building. She reported the facility was working on culture change and voiced change didn't happen overnight. The Administrator reported the facility worked on accountability factors with the staff, working on building an effective nursing administration team, and working on replacing agency staff members. She reported the Corporation assigned the Regional Nurse Consultant to the facility in November and they helped provide support to the facility including training the DON (Director of Nursing).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 44512 potential for actual harm Based on observation, antibiotic stewardship policy, clinical record review, and staff interview, the facility Residents Affected - Many failed to follow policies with all residents. The Infection Preventionist (IP) identified residents with an infection using a facility map, but couldn't provide evidence of when the antibiotic began, the monitoring of laboratory data, and the evaluation of the treated infections. The facility had 2 residents (Residents #43 and #37) with active urinary tract infections (UTIs) and 1 resident (Resident #35) who completed an antibiotic for a methicillin resistant staphylococcus aureus (MRSA) infection (a contagious infection that requires treatment with specific medication due to the infection not responding to other medications). The facility reported a census of 54 residents.

Findings include:

1. The Health Status Note dated 1/16/25 at 7:50 AM reflected Resident #37 returned form an appointment with the following new orders:

a. Start Bactrim DS (antibiotic) 800 - 160 MG 1 tablet by his g-tube (tube inserted in the stomach to bypass

the esophagus to prevent issues with swallowing or increase nutritional intake) for 14 days for a UTI.

The New Order Note dated 1/27/25 at 11:51 AM indicated Resident #37 returned from the Urologist appointment with new orders for the following:

a. Increase urinary catheter changes to every 3 weeks or 21 days.

b. Start nitrofurantoin (antibiotic) 100 milligrams (MG) nightly for 90 days.

c. Start D-Mammose (a sugar that may help treat and prevent UTIs by blocking E. coli bacteria) 1000 MG twice a day

2. Resident #43's Clinical Physician's Order reviewed 2/25/25 listed an order for Cipro oral tablet 250 MG from 2/18/25 - 2/25/25.

3. The Nutrition/Dietary Note dated 2/24/25 at 10:50 AM indicated Resident #35 used an antibiotic due to a diagnosis of MRSA.

During an interview on 2/24/25 at 3:04 PM Staff F reported Resident #35 needed quarantined the previous week but no longer needed.

During an interview on 2/27/25 at 2:17 PM, the Director of Nursing (DON) reported being the current infection Preventionist (IP) and having the responsibility for the infection prevention and antibiotic stewardship program. The DON provided a monthly map of the facility with color coding of infections. The map failed to provide evidence of the antibiotic used for the infections, or the monitoring of the lab data or evidence-based criteria for the evaluation of the treated infections. The DON stated the facility would soon start using a system on the computer that would track the infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 39 165411 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165411 B. Wing 03/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 During an interview on 2/27/25 at 2:29 PM, the Administrator explained she had to get permission before she could provide the infection tracking process due to it being Quality Assurance (QA) material. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/27/25 at 3:02 PM, the Administrator couldn't provide evidence of an active antibiotic stewardship program. Residents Affected - Many

A policy titled Antibiotic Stewardship Program dated 1/23/25 revealed:

a. The antibiotic stewardship program committee included the DON and the Infection Prevention Program Coordinator.

b. The DON was accountable to educate and implement antibiotic stewardship protocol for nursing staff, assess, monitor and communicate changes in the resident's condition by monitoring laboratory/x ray reports associated with the disease. The DON was responsible to communicate results/effectiveness of the antibiotic therapy to the medical provider.

c. The infection Preventionist (IP) gathers data and tracks when antibiotics start, monitoring adherence to evidenced based published criteria during the evaluation and management of the treated infections. The IP reviews the antibiotic resistance patterns and understands which infections are caused by resistant organisms, presents the collected data to the monthly Quality Assurance committee meeting and assists with antibiotic stewardship education to staff, residents and families.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 39 165411