Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southfield Wellness Community during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical diagnoses was being positioned for an x-ray when a radiology technician allegedly placed a gloved hand over the resident’s mouth and told or asked the resident to stop coughing, as witnessed by a CNA. The CNA reported the incident to the nurse, and the next morning a day-shift nurse informed the ADON, who then spoke with the resident and reported the information to the DON and Administrator. Although facility policy required that all abuse allegations be reported to the state agency within 2 hours, the self-report was not submitted until later that day, resulting in a failure to meet the required reporting timeframe.
A resident with impaired cognition and frequent bowel incontinence was left in a soiled brief for an extended period after experiencing multiple episodes of diarrhea. Staff were unable to provide timely incontinence care due to staffing availability and communication lapses, resulting in the resident feeling upset and undignified. Facility policy requires residents to be treated with dignity and respect, but this expectation was not met.
The facility failed to address deficiencies in care planning, ADL care, quality of care, accident prevention, dialysis, nursing staff sufficiency, and QAPI program effectiveness. Despite efforts to implement a culture change and support from a Regional Nurse Consultant, the facility continued to struggle with accountability and effective implementation of their QAPI plan.
The facility failed to implement its antibiotic stewardship program, as the Infection Preventionist could not provide evidence of antibiotic initiation, lab data monitoring, or infection evaluation for residents with infections. The DON, also serving as the IP, did not demonstrate an active stewardship program, and the facility's infection tracking map lacked necessary details. The Administrator was unable to provide evidence of the program, citing Quality Assurance restrictions.
The facility failed to provide scheduled bathing assistance to residents, impacting their personal hygiene and choice. Staffing shortages led to missed baths, with residents reporting fewer showers than scheduled. Documentation confirmed inconsistencies, and the facility lacked a formal bathing policy.
A resident with intact cognition reported experiencing incontinence due to insufficient staffing, which delayed assistance when needed. This led to feelings of indignity, as the resident had to wait for help, resulting in bowel incontinence. The facility's policy emphasizes treating residents with dignity and respect, but the resident's experience indicates a failure to adhere to this policy.
A facility failed to develop a comprehensive Care Plan for a resident with diabetes, dementia, depression, and PTSD. The Care Plan lacked directions for managing diabetes, including insulin usage and blood sugar monitoring, and did not address anti-anxiety medication use. A Nurse Consultant confirmed the deficiency, noting the absence of necessary information for high-risk medications, despite the facility's policy requiring comprehensive Care Plans.
The facility failed to provide restorative care for two residents, one with a stable thoracic spine fracture and another with hemiplegia. The first resident's restorative program was delayed for 18 days, while the second resident received inconsistent care due to staff being reassigned to other duties. The DON did not document or evaluate the residents' progress, leading to deficiencies in their care plans.
A facility failed to notify a physician of significant weight gains in a resident with ESRD, as required by the physician's orders. Despite multiple instances of weight gain exceeding the specified parameters, the facility did not document any notifications to the physician. Interviews with the DON and Administrator confirmed the lack of adherence to the physician's orders, and the facility did not have a specific policy in place, relying instead on the standard of care.
A resident with multiple health conditions, including heart failure and acute kidney failure, had abnormal lab and chest x-ray results that were not promptly addressed by the ARNP. The results, indicating potential heart failure, were faxed to the ARNP, but there was no documented follow-up or communication. The resident continued to experience symptoms and eventually expired without timely intervention. The facility's policy for prompt notification of critical results was not followed, leading to this deficiency.
Several residents reported significant delays in call light responses, with one resident waiting up to 2 hours for assistance in the bathroom, leading to distress and incontinence. The facility's call light policy was not consistently followed, resulting in multiple instances of delayed responses across different residents.
A resident with a suprapubic catheter required a gentamicin bladder irrigation flush, but an agency nurse was unfamiliar with the procedure. Consequently, a CNA, who was not trained for this task, performed the flush with the resident's guidance. The DON and Administrator were unaware of the incident, and the facility's job description for CNAs did not include such medical procedures.
The facility failed to provide necessary assessments and interventions for three residents, compromising their well-being. A resident with heart failure did not receive proper monitoring and documentation of weights and lung sounds, leading to missed medication administration and unaddressed critical lab results. Another resident with impaired cognition had undocumented bruises, and a third resident with chronic edema lacked documentation for compression stockings and weight monitoring, despite significant weight gain.
A resident with severely impaired cognition and multiple health issues experienced a fall resulting in injuries due to inadequate supervision and failure to implement a fall intervention. The facility did not complete a thorough root cause analysis or update the care plan with new interventions. Additionally, necessary therapy evaluations and treatments were not ordered, despite recommendations.
A resident with a history of CHF, renal insufficiency, and COPD experienced repeated paraphimosis due to the facility's failure to properly manage foreskin retraction during catheter care. Despite receiving instructions from a Urology Clinic, the staff did not consistently follow orders to ensure the foreskin was not left behind the head of the penis, leading to significant swelling and pain. The facility's documentation was inconsistent, and staff interviews revealed a lack of training in proper care for an uncircumcised penis.
The facility failed to provide appropriate bladder care for two residents, leading to urethral erosion and paraphimosis in one resident due to improper catheter management, and another resident was found in a urine-soaked bed due to inadequate incontinence care. The facility lacked specific policies and documentation, contributing to these deficiencies.
A resident with a history of dementia and behavioral issues did not receive the correct dosage of Seroquel for seven days due to a pharmacy mix-up. The resident's medication was ordered from the wrong pharmacy, resulting in the continued administration of a lower dosage than prescribed. The error was discovered by a CMA during medication rounds, and the resident's family and PMHNP were informed.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) within the required 2-hour timeframe. The involved resident had severe cognitive impairment, with a BIMS score of 5, and diagnoses including heart failure, hypertension, and traumatic brain injury. A CNA reported that while assisting a radiology technician in positioning the resident for an x-ray, she observed the technician place a gloved hand over the resident’s mouth due to coughing and tell or ask the resident to stop coughing. The CNA then reported this observation to the nurse on duty. The RN confirmed that the CNA reported the technician put a hand on the resident’s mouth and told or asked the resident to quit coughing, and that the CNA’s description made it sound shocking. The RN stated she did not consider this an allegation of abuse and did not report it to the Administrator or DON. A late-entry Health Status Note documented that the following morning the day-shift front nurse informed the ADON, upon arrival to the building, that the radiology technician had put a hand over the resident’s mouth and asked the resident not to cough the previous night, and that the CNA had reported this to the evening nurse. When the ADON spoke with the resident and asked if anything had happened since the previous day, the resident replied that they did not think so. The ADON then reported this information to the DON and Administrator. The facility’s abuse prevention, reporting, and investigation policy required that all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation be reported to DIAL and other required agencies, with abuse or abuse resulting in bodily injury to be reported immediately and not later than 2 hours after the allegation is made. Despite this policy, the facility did not submit the self-report related to this incident until later that day, beyond the 2-hour reporting requirement.
Delay in Incontinence Care Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, dependent on staff for toileting hygiene and frequently incontinent of bowel, was not provided timely personal care after experiencing multiple episodes of diarrhea. Documentation showed the resident had several incidents of incontinence over the course of an evening. The resident required assistance from two staff members for incontinence care and transfers, as outlined in their care plan. On the evening in question, the resident activated their call light after soiling their brief. A CNA responded and informed the resident that assistance would be delayed until another staff member returned from break, as two staff were needed for care. The CNA attempted to find another staff member but became occupied with another resident requiring immediate assistance and forgot to notify the returning staff about the resident's need. As a result, the resident remained in a soiled brief for an extended period, which the resident later described as upsetting and undignified. Interviews with staff and the resident confirmed that the resident was left waiting for incontinence care, and staff acknowledged the resident's right to timely assistance and dignified treatment. The facility's policy emphasized the importance of treating residents with dignity and respect, but this expectation was not met in this instance, as the resident was not promptly attended to during repeated episodes of incontinence.
Facility Fails to Correct Deficiencies in Care and Staffing
Penalty
Summary
The facility failed to correct deficiencies in 7 out of 12 areas of concern, as identified in past surveys and the current survey. These deficiencies include issues with the development and implementation of comprehensive care plans, provision of ADL care for dependent residents, quality of care, and ensuring the environment is free of accident hazards. Additionally, there were concerns related to dialysis, sufficient nursing staff, and the effectiveness of the QAPI program. The facility's QAPI plan, reviewed on January 14, 2024, outlined a mission to provide resident-centered healthcare and promote caregiver engagement, but the survey findings indicate that these goals were not met in practice. The Administrator acknowledged the repeated concerns and noted that the facility was undergoing a culture change, which included changes in nursing administration and efforts to replace agency staff members. Despite these efforts, the facility continued to struggle with accountability and effective implementation of their QAPI plan. The Regional Nurse Consultant was assigned to the facility in November to provide support, including training for the DON, but the deficiencies persisted, indicating a need for further improvement in the facility's systems and processes.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy, as evidenced by the lack of documentation and monitoring of antibiotic use for residents with infections. The Infection Preventionist (IP) identified residents with infections using a facility map but could not provide evidence of when antibiotics were initiated, the monitoring of laboratory data, or the evaluation of treated infections. Specifically, two residents had active urinary tract infections (UTIs), and one resident had completed an antibiotic course for a methicillin-resistant Staphylococcus aureus (MRSA) infection. The Director of Nursing (DON), who also served as the IP, was unable to demonstrate an active antibiotic stewardship program and failed to provide evidence of monitoring or evaluation of antibiotic effectiveness. The facility's policy on antibiotic stewardship required the DON and the Infection Prevention Program Coordinator to educate staff, monitor residents' conditions, and communicate the results of antibiotic therapy to medical providers. However, the DON did not fulfill these responsibilities, as there was no evidence of adherence to evidence-based criteria during the evaluation and management of treated infections. Additionally, the facility's map, which was supposed to track infections, did not include information on the antibiotics used or the monitoring of lab data. The Administrator also could not provide evidence of an active antibiotic stewardship program, citing the need for permission to share the infection tracking process due to its classification as Quality Assurance material.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to residents who were unable to perform this activity of daily living independently. Four residents were identified as not receiving their scheduled showers or baths, which were necessary for maintaining personal hygiene and respecting personal choice. The facility's documentation and interviews with residents and staff revealed inconsistencies in the provision of scheduled bathing services. Resident #6, who required total assistance for bathing due to progressive neurological conditions, diabetes mellitus, and multiple sclerosis, reported receiving showers only every other day instead of daily as scheduled. Documentation confirmed missed showers on specific dates, and staff interviews indicated that staffing shortages, particularly on weekends, led to the reassignment of bath aides to other duties, resulting in missed baths for residents. Similarly, Resident #27, who required substantial assistance for bathing, did not receive showers on all scheduled days, with documentation showing missed and refused baths. Resident #48, who also required assistance, reported receiving fewer showers than scheduled, particularly on Saturdays. Resident #24, dependent on staff for bathing, received only two baths since admission, with no documentation of refusals or attempts to encourage bathing. The Director of Nursing acknowledged the staffing issues and the impact on bathing schedules, but the facility lacked a formal bathing policy, relying instead on a standard of care.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to provide care that promotes dignity and respect for one resident, identified as Resident #24, out of 21 residents reviewed. Resident #24, who has intact cognition as indicated by a BIMS score of 14, reported experiencing incontinence of bowel movements on a couple of occasions since being admitted to the facility. The resident attributed these incidents to insufficient staffing, which delayed assistance when she needed help. She expressed feeling like a baby when these incidents occurred. The facility's policy on Resident Rights - Dignity and Respect, revised in April 2024, emphasizes treating residents with dignity and respect, and providing considerate and respectful care with reasonable accommodation of individual needs. However, the resident's experience suggests a failure to adhere to this policy, as she had to wait for assistance, leading to incontinence and a loss of dignity.
Incomplete Care Plan for Resident with Multiple Conditions
Penalty
Summary
The facility failed to develop a comprehensive Care Plan for a resident, identified as Resident #13, who was at risk due to multiple medical conditions including diabetes mellitus, non-Alzheimer's dementia, depression, and PTSD. The resident's Minimum Data Set (MDS) assessment indicated intact cognition and documented the use of anti-anxiety and hypoglycemic medications. Despite these complexities, the Care Plan lacked specific directions for managing type 2 diabetes mellitus, including insulin usage, blood sugar monitoring, and parameters for physician notification. Additionally, the Care Plan did not address the use of anti-anxiety medication, its potential side effects, or monitoring requirements. The deficiency was confirmed by a Nurse Consultant, who acknowledged that the current Care Plan did not include necessary information regarding high-risk medications. The facility's Care Plan Policy, revised in July 2023, mandates that Care Plans be developed in accordance with federal regulations and be reviewed and revised by the Interdisciplinary Team following MDS assessments or any changes that necessitate a revision. However, the facility failed to adhere to this policy, resulting in an incomplete Care Plan for Resident #13.
Failure to Provide Restorative Care for Residents
Penalty
Summary
The facility failed to provide restorative care for two residents, leading to deficiencies in their care plans. Resident #43, who had a stable fracture of the thoracic spine and muscle weakness, was recommended for a restorative maintenance program by the Physical Therapist (PT) on February 7, 2025. However, the facility did not initiate this program for 18 days, and the resident's care plan lacked the necessary restorative program. Despite the PT and Director of Nursing (DON) signing a document indicating the setup of a restorative program, it was not completed, as confirmed by an email from the Administrator. Resident #46, diagnosed with hemiplegia and requiring substantial assistance for transfers and toileting, did not receive the recommended restorative care as prescribed. The Point of Care (POC) Response History showed inconsistent completion of the restorative program, with several instances of zero minutes recorded. Interviews revealed that the Restorative Aide was often pulled to perform CNA duties, limiting the time available for restorative care. The DON, responsible for overseeing the restorative program, admitted to not documenting or evaluating the progress of residents in the program, contributing to the deficiency.
Failure to Notify Physician of Weight Gains in Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease (ESRD) by not notifying the primary care physician (PCP) of significant weight gains as per the physician's orders. The resident, who had intact cognition and was diagnosed with medically complex conditions including heart failure and hyperlipidemia, was supposed to have daily weights monitored, with any weight gain of 2-3 pounds in 24 hours or 5 pounds in 5 days reported to the physician. However, the clinical record lacked documentation of such notifications despite multiple instances of weight gain exceeding these parameters over a period of several months. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not notify the physician about the resident's weight changes as ordered. The DON was unable to locate any physician notifications related to the weight gains, and the Administrator acknowledged that the staff did not follow the physician's orders. The facility did not have a specific policy regarding this issue, relying instead on the standard of care, which was not adhered to in this case.
Failure to Ensure Timely Physician Response to Abnormal Lab and X-ray Results
Penalty
Summary
The facility failed to ensure timely response from a physician to abnormal laboratory and chest x-ray results for a resident with multiple health conditions, including heart failure, hypertension, atrial fibrillation, diabetes mellitus, and acute kidney failure. The resident required significant assistance with mobility and had moderately impaired cognition. An Advanced Registered Nurse Practitioner (ARNP) ordered several lab tests and a chest x-ray, which revealed significant abnormalities, including high BNP levels indicating potential heart failure or other serious conditions. The lab results were faxed to the ARNP, but there was no documented follow-up or communication from the ARNP regarding these results. Similarly, the abnormal chest x-ray results were faxed, but again, there was no documented response or follow-up from the ARNP. The resident continued to experience symptoms such as increased weight gain and pitting edema, and eventually expired without the abnormalities being addressed in a timely manner. The ARNP reported not being available over the weekend when the results were received and stated that a hospitalist was covering for her. However, there was no evidence of the hospitalist reviewing the results either. The facility's policy required prompt notification of critical lab and radiology results to the attending physician or an appropriate practitioner, but this protocol was not followed, contributing to the deficiency.
Delayed Call Light Responses Lead to Resident Distress
Penalty
Summary
The facility staff failed to consistently answer call lights within a reasonable amount of time, as evidenced by multiple residents reporting significant delays. Resident #46, who has hemiplegia and requires substantial assistance for transfers and toileting, reported waiting 30 minutes to an hour for call light responses, with documented instances of delays ranging from 18 minutes to over an hour. Additionally, Resident #46 experienced a broken call light pendant that was not promptly replaced, further complicating their ability to request assistance. Resident #6, who requires total assistance for toileting hygiene and lower body dressing due to progressive neurological conditions, reported waiting for 2 hours in the bathroom over a weekend when the facility was understaffed. The call light report for Resident #6 showed 12 instances of waiting over 20 minutes for a response within a 30-day period. Similarly, Resident #24 experienced incontinence due to delayed responses, with call light times exceeding 15 minutes on multiple occasions, including a significant delay in receiving requested medication. Resident #13, who also has intact cognition, reported waiting up to 30 minutes for call light responses, resulting in incontinence and embarrassment. The facility's call light policy, which mandates prompt responses, was not adhered to, as evidenced by numerous documented instances of delayed responses across multiple residents. The facility's administrator acknowledged the expectation for call lights to be answered within 15 minutes, highlighting a systemic issue in meeting this standard.
Inadequate Staff Training Leads to Improper Catheter Flush
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies to perform a catheter flush for a resident, leading to a deficiency. A resident with intact cognition and medical conditions including neurogenic bladder and multiple sclerosis required a suprapubic catheter flush with gentamicin bladder irrigation as ordered. However, on a specific date, an agency nurse on duty was unfamiliar with the procedure and did not perform the flush. Instead, a CNA, who was not trained or qualified to perform this task, conducted the flush with the resident's guidance. The CNA admitted to performing the procedure without proper training and acknowledged that it was beyond her scope of practice. The Director of Nursing (DON) and the Administrator were unaware of the incident until it was reported. The CNA stated she left a note for the DON, but the DON claimed not to have received it. The facility's job description for CNAs did not include performing such medical procedures, and both the DON and Administrator expected staff to adhere to their scope of practice. The incident highlights a lapse in ensuring that only qualified personnel perform specific medical tasks, as well as a communication breakdown within the facility's management.
Failure to Provide Necessary Assessments and Interventions for Residents
Penalty
Summary
The facility failed to provide necessary assessments and interventions for three residents, compromising their highest practical physical well-being. Resident #55, with a history of heart failure, hypertension, and diabetes, did not receive proper monitoring and documentation of daily weights and lung sounds, despite physician orders. The lack of documentation led to missed opportunities to administer additional Lasix when needed, and abnormal lab results and chest x-ray findings were not addressed in a timely manner. Resident #55 ultimately expired, with no evidence that the ARNP addressed the critical lab and x-ray results before the resident's death. Resident #20, who had severely impaired cognition and a history of anemia and heart failure, was found with multiple bruises on her right hand and arm. The clinical record lacked documentation, assessments, or notifications regarding these bruises. Staff interviews revealed that the facility's policy required observation and documentation of new skin areas, but this was not followed. The facility was in the process of implementing weekly skin assessments, but not all residents had these assessments in place at the time of the survey. Resident #27, with intact cognition and a history of hypertension and chronic edema, did not have proper documentation for the use of compression stockings or orders for daily weights. Despite significant weight gain over several months, there was no evidence of physician notification or follow-up. The ARNP expected daily weights and notification of weight changes, but the facility did not have an order for weights and failed to track them consistently. The DON acknowledged the lack of documentation and follow-up, indicating a failure to adhere to standard practices for residents with chronic edema and diuretic use.
Inadequate Supervision and Fall Intervention for Resident
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident with severely impaired cognition, as evidenced by a fall incident. The resident, who required substantial to maximal assistance with bed mobility and transfers, experienced a fall resulting in skin tears to the right elbow and knee. The incident occurred as the resident was being assisted from the bathroom to a wheelchair, where they tripped over their own feet. Despite the presence of a gait belt and walker, the facility did not complete a thorough root cause analysis to determine why the resident lost footing or tripped, nor did they implement a fall intervention following the incident. The facility's documentation was lacking in several areas, including the absence of a physician order for an occupational therapy evaluation and treatment, as initially recommended. Additionally, the root cause analysis did not adequately address the cause of the fall, and the care plan was not updated with a new fall intervention. Interviews with facility staff revealed that the previous Director of Nursing intended to obtain physical therapy orders due to the resident's weakness but failed to follow through. The facility's policy required a comprehensive assessment and intervention plan following a fall, which was not adhered to in this case.
Failure to Manage Paraphimosis in Resident
Penalty
Summary
The facility failed to routinely assess and provide interventions for retracting the foreskin of the penis and returning it to its original position for a resident, leading to repeated instances of paraphimosis. The resident, who had a history of congestive heart failure, renal insufficiency, and chronic obstructive pulmonary disease, required intervention at a Urology Clinic on three separate occasions to reduce paraphimosis. Despite having a catheter in place and orders to ensure the foreskin was not left behind the head of the penis, the facility's staff did not consistently follow these instructions, resulting in significant swelling and pain for the resident. The resident's medical records indicated that the foreskin was not properly managed during catheter care, leading to repeated swelling and paraphimosis. The Urology Clinic provided education to the nursing home staff on the importance of retracting the foreskin back over the head of the penis after catheter care, but the facility failed to implement these instructions effectively. The resident's foreskin was found retracted and swollen on multiple occasions, and the facility's documentation did not consistently reflect the interventions or assessments required to address the issue. Interviews with staff revealed a lack of consistent training and understanding of the proper care for an uncircumcised penis, contributing to the ongoing issue. Despite receiving orders and education from the Urology Clinic, the facility's staff did not consistently apply the necessary care, resulting in the resident experiencing pain and requiring repeated medical interventions. The facility's documentation was also found to be lacking, with discrepancies between reported care and the resident's condition upon examination by external medical providers.
Deficiencies in Bladder and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate bladder care and services for two residents, leading to significant deficiencies. One resident, who had a urinary catheter due to obstructive uropathy, experienced urethral erosion and paraphimosis due to improper catheter management. The facility did not use a secure device to hold the catheter in place, resulting in pulling and tension on the catheter. Additionally, the facility did not document the resident's urinary output during a voiding trial, and the resident retained over 1 liter of urine, indicating a lack of proper monitoring and assessment. Another resident, who was frequently incontinent of bowel and bladder, was found in a urine-soaked bed, indicating a failure to provide timely incontinence care. The resident's care plan lacked specific directions on how often to check for incontinence, and staff did not perform incontinence care as expected. The resident's daughter had instructed staff to let the resident sleep, but staff failed to report the situation to the charge nurse, resulting in the resident remaining in a wet bed for an extended period. The facility's policies and procedures for catheter and incontinence care were inadequate, contributing to the deficiencies. The facility did not have a policy related to urinary incontinence and relied on standard practices, which were not effectively implemented. The lack of documentation, monitoring, and adherence to care plans led to the residents' compromised care and the facility's failure to meet the required standards for bladder and incontinence care.
Medication Administration Error Due to Pharmacy Mix-Up
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for a resident by not following physician orders to administer the correct dose of an antipsychotic medication for seven days. The resident, who had moderately impaired cognition and required assistance with mobility, had a history of hypertension, renal disease, cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, and neurocognitive disorder with Lewy bodies. The resident exhibited delusions, hallucinations, and behavioral symptoms that could present a danger to himself and others, necessitating the use of antipsychotic medication. On a specific date, the resident became agitated and attempted to physically harm staff and other residents. Following this incident, a new order was received to increase the resident's Seroquel dosage to 50 mg every morning and to start Ativan as needed. However, the facility's Medication Administration Record (MAR) indicated that the resident continued to receive the previous dosage of Seroquel, 25 mg in the morning, due to a medication error. The error occurred because the medication was ordered from the wrong pharmacy, and the new dosage was not administered as prescribed. The facility's investigation revealed that the medication error was identified by a Certified Medication Aide (CMA) who noticed the discrepancy while passing medications. The error was attributed to the resident's switch in pharmacies with a change in the level of care, and the pharmacy that received the script did not fill the order or notify the facility. The Director of Nursing (DON) confirmed that the staff continued to administer the incorrect dosage for several days, and the resident's family and the Psychiatric Mental Health Nurse Practitioner (PMHNP) were notified of the error.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Webster City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestview Nursing And Rehabilitation | 0.5 mi | — | 13 | 0 |
| Stratford Specialty Care | 14.8 mi | — | 5 | 0 |
| Rotary Senior Living | 14.8 mi | — | 3 | 1 |
| Opco Dayton Ia Llc | 17.9 mi | — | 9 | 0 |
| Marian Home | 18.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.