Southfield Wellness Community

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations, resident, and staff interviews the facility failed to provide the residents with a comfortable homelike environment by failing to keep a resident bed in functioning order and the toilet properly maintained. The facility reported a census of 56 residents. Findings include:Observation on 9/29/25 at 11:20 a.m., revealed, the footboard in Resident #1's room, split in half with silver brackets placed

on the inside holding the foot board together.Observation on 9/30/25 at 1:30 p.m., revealed the footboard in Resident #1's room, split in half with silver brackets placed on the inside holding the footboard together.Interview on 9/30/25 at 1:30 p.m., Resident #1 explained the footboard has been broken since they admitted to the facility in July and they are afraid to sleep in the bed causing the footboard to break and falling out of bed. Resident #1 also commented that their bathroom toilet was not working for a couple of days and that they had to use a commode and is embarrassed with the commode still in their room.A work order, given to the surveyor on 10/1/25 at 2:00 p.m., by the Administrator, documented a created dated 8/13/25 at 5:00 p.m., toilet is now broken, work order for new toilet in progress.A receipt dated 8/14/25 at 12:15 p.m., documented toilet purchased due to needing replaced.Interview on 10/1/25 at 9:45 a.m., Staff A, Maintenance, and Staff B, Maintenance, confirmed that Resident #1 toilet was broken for a couple of days a month ago, not sure of the exact date, and that a work order was filled out. Staff B replaced the foot board on the evening of 9/30/25, when they became aware by the surveyor that it was broken, and was not aware on how long the foot board had been broken. Staff A stated that staff pull on the foot board and they break easily. Staff A and Staff B were not aware of any audits or scheduled room checks to be completed for residents' beds, toilets or furnishing.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

floor facing the bathroom on his hands and knees.The Health Status Note dated 7/30/25 at 8:40 AM, late entry, documented, Resident has had a change in cognition over the recent months. Seems to have more difficulty with understanding what is being asked of him. If RN tells him to sit down in the chair, resident will look at the chair but then is confused on how to sit. This makes cueing resident to complete a task much more difficult and can be time consuming. At times resident will get frustrated. CNA was ambulating with resident back from the dining room post breakfast when RN hears CNA say, Ow, Ow, stop squeezing my hand. Resident continues to squeeze CNA hand and had to pry resident's hand off. Then resident is guided/assisted to sit in the chair at the nurses' station. The resident turns and is looking at the seat but missing it when sits. The resident had to be lifted into the chair by 2 staff, then lifted back in the chair by 3 staff. It's not that the resident can't do it, it's that resident is not understanding how to do it in the moment.

Cognition fluctuates from day to day, every day is different. The Incident Report dated 8/3/25 at 3:05 AM, documented, the nurse and another staff member looked down the hall and noticed the resident lying on

the floor outside of his room, in the hallway. The nurse and staff went to the resident's aid. Resident was observed lying on the floor with only socks on. Blood noted on floor in several spots near resident.New Order follow up note dated 8/8/25 at 00:19 AM, documented Resident received the decreased doses of Haloperidol, Wellbutrin and benztropine today. Resident came out to hallway to walk around. This nurse asked if he like to sit in a chair for a bit. Resident sat in a chair, near the back nurses' station. Resident was pleasant and cooperative with staff. Resident then went back to his room and has been resting in bed with eyes closed.The Pharmacy Review-Gradual Dose Reduction (GDR) request for Psychotropic Medications dated 1/19/25, recommended to please follow up with the Provider on the next visit for continued need for Haldol oral tablet 2 mg, Give 0.5 tablet by mouth one time a day at lunch and Haldol oral tablet 2 mg, give 1 tablet by mouth two times a day. If a dose reduction is not in his best interest, please note a patient specific clinical rationale below. The form signed by the provider on 4/22/25, Patient is stable on current medications and likely to have harm with GDR attempt after previous failed GDR attempts.Interview on 10/2/25 at 9:00 AM, the facility Director of Nursing, acknowledged that the resident received a lot of psychotropic medications and that the clinical record lacked documentation of a GDR or an attempt to decrease the medications to see if that contributed to the change in condition or falls. The DON verified that it is the goal of the facility is keeping resident off as many medications that they can, that are not necessary. The DON stated that the facility follows the guidelines for Unnecessary Medications per the State Operations Manual.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident denied pain. Continue to monitor.The Communication Report with the Resident on 7/20/25 at 11:11 PM, indicated the Suprapubic catheter changed per schedule. Catheter changed using silicone catheter, using sterile technique. Immediate return of straw-colored urine. Some discomfort with insertion.

Catheter is patent and draining.The Status Note dated 7/24/25 at 10:06 AM, indicated that a phone call was placed to clinic. Resident has dried blood around catheter site and is complaining of same pain. Resident had only a small amount of urine in her catheter bag but stated that she was soaked this morning. Waiting for a return call.The New Order Note dated 7/25/25 at 4:10 PM, indicated that the resident returned from appointment without incident. Catheter was changed at appointment with the doctor (Dr.) using a Silastic catheter. Resident returned with the following directions. Plan: Suprapubic tube exchanged today-Continue every two-week exchange using silastic catheter NOT silicone.The Health Status Note dated 7/29/25 at 10:53 AM, indicated a phone call placed to physician about resident having blood around catheter site and having discomfort around insertion site. Spoke with receptionist and gave an update, then spoke to the nurse. She was going to talk with Dr. and call back. She stated that the blood is more than likely from the irritation from the previous catheter.The Health Status Note dated 7/29/25 at 2:56 PM, indicated that the Dr.'s nurse returned call, Dr. stated that no change from appointment on Friday. Stated that to continue to monitor resident, but it would take time for her to heal due to the previous catheter that was being used.The Progress Notes from the Office visit dated 7/25/25, indicated the resident returned in follow up for a chief complaint of a suprapubic catheter obstruction. Resident has a history of neurogenic bladder secondary to Multiple Sclerosis and now living with a chronic suprapubic catheter which is exchanged monthly by her home nurse. She was seen in the emergency room on 7/4/25 with catheter obstruction and leaking around

the suprapubic site. Apparently, the suprapubic catheter had exited the urethra and was in the vagina, but it was exchanged in the ER and obstructed urine was drained. She continued to have some bleeding around

the suprapubic site. They are using a silicone catheter. Plan is to continue every 2-week exchange using catheter (latex or silastic is fine but NOT silicone).Interview on 9/30/25 at 1:00 PM, Resident #3, stated that

the nurse attempted to put the silicone catheter into the suprapubic site at least 4 times. The end of the catheter that was being used had a square end on it and would get caught. Resident #3 expressed concerns that the nurse was using the wrong type of catheter and that caused the stoma to get irritated and sore, and orders were received for an ointment to be used. The resident reported that she knows her body very well and that a silastic catheter tubing works the best.Interview on 9/30/25 at 2:00 PM, Staff C, Registered Nurse (RN), stated that a silastic catheter is the type of catheter that the physician ordered for Resident #3. Staff C explained that on 7/3/25, a CNA came and explained that something was wrong with

the catheter with Resident #3. Staff C indicated that when she went to investigate, she noticed that a catheter was in the vagina of the resident. Staff C indicated that the catheter was not a silastic catheter tubing and confirmed that it was a silicone catheter. Interview on 10/2/25 at 11:00 AM, the facility's Director of Nursing (DON) confirmed that the staff are expected to follow the physician's orders as directed by using

a silastic catheter and not a silicone. The DON explained that the facility followed the standards of practice for following physician orders.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, clinical record review, staff and resident interview, the facility failed to assess a resident that had no urinary output in their catheter bag for two days for which resulted in the resident going to the Emergency Department with discomfort (Resident #3) for 1 of 3 resident reviewed. The facility identified a census of 56 residents.Findings include:Resident #3 Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired cognitive decisions, is able to be understood and understands and no behavior or mood issues.

The resident required dependent assistance for activity of daily livings (ADL) and an indwelling catheter used for urinary output. The MDS included diagnoses of neurogenic bladder, (an injury or disease that interrupts the electrical signals between your nervous system and bladder function) diabetes mellitus, pneumonia, multiple sclerosis, depression and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection).The Care Plan Focus with a target dated 11/23/25, indicated Resident #3 received an antibiotic therapy related to chronic catheter and urinary tract infections (UTI), and is at risk for complications related to chronic urinary disturbance. Interventions include to encourage to drink fluids, medications as ordered and observe for signs and symptoms of UTI, monitor for pain/discomfort due to catheter use.The Documentation Survey Report dated July 2025, indicated no urinary output on the following shift and dates.a. Night shift: 7/1/25, 7/3/25 and 7/4/25b. Day shift: 7/2/25, and 7/3/25.The Health Status Note dated 7/3/25 at 4:36 PM, identified that the Certified Nursing Assistants (CNA) report that resident has not had any output in her catheter drainage bag for the last 2 days and has been very wet/incontinent of urine. Registered Nurse (RN) to check if catheter needed to be repositioned or changed due to occlusion. Balloon is deflated and deep dark red blood is noted in the tubing. New catheter placed with only small amount of urine obtained. Clinic reports to monitor for urine output. If resident spikes

a temperature, has a moderate amount of bleeding, or significant amount of pain, it is suggested resident be evaluated in the Emergency Room.The Health Status Note dated 7/4/25 at 12:25 PM, documented the nurse was called into residents' room this morning. Resident had very little output and her brief was drenched. Asked resident if she wanted to go to the ER. Resident was transported via facility van.The Health Status Note dated 7/4/25 at 4:57 PM, documented resident returned with diagnosis of obstruction of suprapubic catheter and had a new catheter placed. The After Visit Summary Note dated 7/4/25, documented reason for visit as urinary retention, diagnosis of obstruction of suprapubic catheter.Interview

on 9/30/25 at 1:00 PM, Resident #3 acknowledged and verified that she had no urinary output for 2 days and had pain/discomfort and requested to go to the Emergency Room.Interview on 9/30/25 at 2:00 PM, Staff C, Registered Nurse (RN), verified Resident #3 had no urinary output for 2 days and it is the expectation of the staff to notify if no urinary output after one shift.Interview on 10/2/25 at 11:00 AM, the facility Director of Nursing acknowledged Resident #3 had no urinary output for 2 days and that it is the expectation of the floor staff to notify the charge nurse if no urinary output at the end of their shift. The Director of Nursing stated that the facility follows the standards of practice for documenting urinary output.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical document review, resident and staff interview, the facility failed to provide adequate nursing supervision for 1 of 3 residents (Resident #4) reviewed. The facility reported a census of 56 residents.

Findings include:Resident #4's Minimum Data Set (MDS) assessment dated [DATE REDACTED], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 for which indicated no impaired cognitive decisions, is able to be understood and understands and no behaviors. The resident required partial to moderate assistance with activity of daily living and had 2 falls with no injury prior to being admitted to the facility. The MDS included diagnoses of heart failure, hypertension, diabetes mellitus, Parkinsons, anxiety, and depression.The Care Plan Focus target dated 12/4/25, indicated Resident #4 is at risk for falls related to gait imbalance. Interventions include to assist resident with ambulation and transfers as needed, bed is in low position, resident to leave bedroom door open for closer supervision and signage

on walker to remind resident to use assistive device and call for assistance.The Incident Report dated 8/12/25 at 8:35 AM, described the situation as nurse called to resident's room. Observed resident sitting on

the floor in front of the bathroom door with scooter on his left side. Certified Nursing Assistant (CNA) was walking by resident room and witnessed him lowering himself to the floor and resident did not hit his head.

Resident wearing appropriate footwear, call light pendent around neck, resident checked on hourly and door open for closer observation.The Incident Report dated 8/2/25 at 3:15 PM, described the situation as nurse was called to resident room that resident was on the floor. Resident said he took himself to the bathroom and was washing his hands when knee gave out. Further preventative measures include to check

on resident hourly to see if he needs assistance.The Incident Report dated 8/15/25 at 9:15 PM, described that CNA went to answer call light when opened the door noted resident on the floor in front of recliner. Left side against recliner and right hand on the walker. Further preventative measures include to door to room to be left open when alone in room.The Incident Report dated 8/15/25 at 10:00 PM, described the situation as CNA opened the door of room and witnessed start of fall but could not get to resident in time. Reports resident did not hit head. Interview on 9/30/25 at 3:00 PM, Resident #4 was not able to recall if staff check

on him every hour but stated that his room door is closed frequently.Interview on 10/1/25 at 2:45 PM, the facility Director of Nursing acknowledged that the clinical record lacked documentation of hourly checks being completed and the expectation is the staff are to complete since it was an intervention. The facility does not have a policy on falls.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic health records (EHR), document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 4 residents reviewed (Residents #1, #3, #4, and #6). The facility reported a census of 56 residents.Findings include: 1. The Minimum Data Set (MDS) dated [DATE REDACTED] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 6 indicating cognitive impairment. Review of Electronic Health Record (EHR) documented Resident #1 resided in room D17.Interview on 9/30/25 at 1:30 PM Resident #1 stated the facility was short of staff on the evening shift. Resident #9 stated she had to wait longer than 15 minutes to have her call light answered. Review of document titled, Past Call Report for room number D17 documented on 9/28/25 call light was turned on at 10:37 AM and to room elapsed time of 18 minutes.2. The MDS dated [DATE REDACTED] for Resident #3 documented a BIMS score of 15 for which indicated no cognitive impairment.Review of the EHR documented Resident #3 resided in room D23.Interview on 9/30/25 at 1:00 PM, Resident #3 stated that she had to wait longer than 15 minutes to have her call light answered.Review of the document titled, Past Call Report for room number D23 documented on 9/28/25 call light was turned

on at 10:02 PM and to room elapsed time of 20 minutes.3. The MDS dated [DATE REDACTED] for Resident #4 documented a BIMS score of 14 for which indicated no cognitive impairment.Review of the EHR documented Resident #4 resided in room C14Review of the document titled, Past Call Report for room number C14, documented on 9/26/25, call light was turned on at 8:31 AM and to room elapsed time of 22 minutes, on 9/27/25, call light was turned on at 6:21 AM and to room elapsed time of 22 minutes and on 9/29/25, call light was turned on at 6:29 PM with to room elapsed time of 24 minutes.4. The MDS dated [DATE REDACTED] for Resident #6 documented a BIMS score of 15 for which indicated no cognitive impairment.Review of the EHR documented Resident #6 resided in room B42Interview on 9/30/25 at 8:30 AM, Resident #6 stated that it takes longer than 15 minutes to have her call light answered.Review of the document titled, Past Call Report for room number B42 documented on 9/27/25, call light was turned on 5:14 AM and to room elapsed time of 16 minutes. On 9/29/25, call light was turned on at 12:50 PM and to room elapsed time of 21 minutes. Interview on 9/30/25 at 2:15 PM, Staff D, Licensed Practical Nurse (LPN), acknowledged that the call lights take longer than 15 minutes to answer on the evening shift due to short of staff.Interview on 10/1/25 at 2:00 PM, the facility Administrator and Director of Nursing acknowledged that

the call lights are over the 15 minutes and that the expecation are for staff to answer within the 15 minutes per the guidelines.Interview on 10/1/25 at 4:45 PM, Staff E, Certified Nursing Assistant (CNA), verified that

it takes longer than 15 minutes to answer call lights due to short staff on the evening shift.The Call Light Policy dated September 2023, instructed to ensure a prompt response to the residents call for assistance.

The facility also ensures that the call system is in proper working order. Facility shall answer call lights in a timely manner.

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