Southfield Wellness Community
Southfield Wellness Community in Webster City, IA — inspection on March 3, 2025.
Found 13 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
resident interviews, staff interview and policy review, the facility failed to provide care for 1 out of 21
census of 54 residents.
Findings include: Resident #24's Minimum Data Set (MDS) assessment dated [DATE]identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.
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 when she became incontinent.
On 2/26/25 at 4:00 PM, the Administrator reported she expected staff to treat residents with respect, dignity, and provide them care as soon as possible.
On 2/27/25 at 8:30 AM, Resident #24 reported she knew when she needed to have a BM and became incontinent of BM a couple times recently as she waited for someone to help her.
The facility policy titled Resident Rights - Dignity and Respect revised April 2024 defined the purpose of the policy as to lay the foundation for treating all residents with dignity, respect, and maintaining and enhancing his or her self esteem and self worth. In addition, the policy directed that each resident has the right to considerate, respectful care, treated with honesty, dignity and with reasonable accommodation of individual needs except where the health, safety, or rights of the resident or other individuals in the facility would be endangered.
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
including the completion of the Baseline Care Plan within 48 hours of admission and a comprehensive
assessments when applicable and with changes that warrant a Care Plan revision.
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
ordered.
Planned and evaluated for progress. b.
Measurable objectives and interventions documented in the Care Plan. c.
Evidence of periodic evaluation by a licensed nurse in the clinical record. d.
Nursing assistants trained in the techniques that promote resident function. e.
These activities are carried out or supervised by members of the nursing staff. f.
The technique, procedure, or activity is practiced for a total of at least 15 minutes over a 24-hour time period. g. A licensed nurse should evaluate the resident's program for appropriateness. h.
The rehabilitation/restorative summary will be documented according to the following schedule: i.
With each assessment admission, annual, change of condition, and/or quarterly. ii.
When the resident is discharged from the rehabilitation/restorative program.
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
the documentation Resident #24 received two baths since admission on [DATE].
shower or bathe.
On 2/25/25 at 11:22 AM, Staff G, RN (Registered Nurse), reported the only place she knew the staff documented bathing was in the computer.
When asked who had the responsibility to give baths when they didn't have a bath aide scheduled, Staff G referred the question to the DON.
On 2/25/25 at 11:25 AM, the DON reported the facility attempted to schedule a bath aide daily.
The DON described the bath aide position as not essential. At times they pulled the bath aide to the floor to work as a CNA (certified nursing assistant).
The DON reported she expected the CNAs to complete the baths as much as possible when they didn't have a bath aide.
She reported the facility faced staffing issues and were bringing agency staff in the building.
When asked if there were concerns with getting baths done, she said yes, they had a problem sometimes.
On 2/25/25 at 11:50 AM, Staff H, RN, reported they documented baths under tasks in the electronic health record.
She reported Resident #24 had their baths scheduled for Monday and Thursday.
She verified Resident #24 had two baths documented since admission.
When asked if there were concerns with getting baths done, she said yes.
She reported the facility attempted to schedule two bath aides one for the front and one for the back of the building but then the bath aides are pulled to work the floor due to staffing concerns and then baths don't get done.
Staff H said the staff try to work in the missed baths but there are 7 12 baths scheduled every day so it is hard to fit more baths in.
Staff H reported that usually if a resident missed a bath, the bath was not done again until the next scheduled bath day.
On 2/25/25 at 12:22 PM, the DON reported she expected the staff to offer residents a bath at a minimum 2 times per week and if a resident refused a bath that the staff reproach and reoffer the bath that day.
The DON reported she expected the nurses to document refusals in the progress notes.
On 2/25/25 at 3:11 PM, the Administrator reported the facility didn't have a bathing policy and they follow the standard of care.
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
patient experience a new non pressure injury:
c.
Notify the family/responsible party d.
Communicate findings to interdisciplinary team for additional evaluation needed e.
Enter the event in the electronic Risk Management System if applicable (bruises of unknown origin).
Determine the root cause and initiate modifications in the patient's plan of care as indicated. f.
Document in the patient's electronic health record
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
described Resident #20 as weak and lost her footing.
The note recommended a PT (Physical Therapy)
treatment. Resident #20's Care Plan lacked documentation of a fall intervention for 11/21/24.
On 2/26/25 at 11:35 AM, the Administrator reported an OT evaluation and treat as the preliminary recommendation and upon further investigation by the former DON (Director of Nursing) she determined that PT (Physical Therapy) should be ordered and it did not happen.
On 2/26/25 at 4:00 PM, Staff A, Nurse Consultant reported the facility completed a root cause analysis under risk management but it wasn't good.
She reported the previous DON planned to get PT orders due to weakness but did not follow through.
The facility policy titled Fall Risk Assessment and Intervention revised 6/25/12 instructed the facility to assess residents upon admission, readmission, and change in condition for potential risk factors associated with falls.
Initial interventions specific to the resident would be implemented at the time of the assessment.
The policy directed to complete an incident report and quality assurance investigation form should a resident experience a fall.
Assess each fall to try to determine the cause.
Review the Care Plan with each occurrence and add new/different approach relative to the assessed cause of the fall.
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
During an interview 2/27/25 at 1:50 PM, the Director of Nursing (DON) reported she couldn't locate the physician notifications related to Resident #34's weight gains.
The DON acknowledged no one notified the physician about Resident #34's weight changes as ordered.
During an interview 2/27/25 at 3:25 PM, the Administrator said she expected the staff to follow physician's orders.
The Administrator stated the facility didn't have a policy regarding this, as they use the standard of care.
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
ray on [DATE] after Resident #55 has expired.
on [DATE] at 1:49 PM the ARNP reviewed the abnormal lab results and directed her nurse to call the
the ARNP's nurse spoke to a facility nurse on [DATE] 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] at 5:50 PM, Staff A, Nurse Consultant, verified the facility faxed the lab results on [DATE] (Sunday) and the Provider didn't review them until [DATE].
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].
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] at 11:27 AM, the ARNP reported she didn't provide coverage over the weekend ([DATE]) and that a hospitalist covered for her.
The ARNP reported she not being in work status on 11/25 and 11/26.
She said she returned to work status on 11/27 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].
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].
She reported she looked for the chest x ray results in the chart last night ([DATE]) and the next morning ([DATE]), 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] or [DATE].
She said the following week she had clinic day on Thursday, [DATE] 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] 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.
A facility policy titled Laboratory/Diagnostic Value Reporting revised [DATE] directed to promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist of laboratory, radiology and other diagnostic services with results that are in a critical reference range.
The policy directed the facility 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 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.
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the bathroom for toileting hygiene. Resident #6 stated she had times at night when the facility only
partially clothed, while she sat on the toilet for 2 hours waiting for someone to help.
She reported her
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
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
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.
d.
Free of accident hazards/supervision/devices
e.
Dialysis f.
Sufficient Nursing Staff 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).
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
antibiotic stewardship program.
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.
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Southfield Wellness Community 2416 Des Moines Street Webster City, IA 50595
Review of the clinical record lacked documentation that the ARNP addressed the abnormal lab results faxed on [DATE].
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].
The progress notes lacked any follow up or other means of communication with the ARNP regarding the abnormal chest x ray results.
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Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.