Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 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.
Failure to notify physician and wound center of wound VAC hold: A resident with a stage 4 sacral pressure ulcer and intact cognition had NPWT started, then placed on hold when supplies were unavailable and the prior Dakin’s packing treatment was restarted. The record lacked documentation that the physician or wound center was notified, and the DON and wound center RN both confirmed the wound center had not been informed.
A resident with dementia, depression, bipolar disorder, PTSD, and other mental health diagnoses was receiving an antipsychotic medication, but the facility did not submit a Level 2 PASRR after the new diagnoses and medication change. The record showed only a prior Level 1 PASRR, and staff reported the communication process for notifying the SW about new mental health diagnoses or psychotropic meds was missed.
Failure to Resubmit PASRR Level II Evaluation: A resident with schizophrenia and moderate cognitive impairment had a short-term PASRR Level II approval that expired, but the record lacked evidence of a timely resubmission. Social Services stated the resubmission date was missed, and the PASRR was later resubmitted and queued for review. The Administrator reported the facility had no specific PASRR policy and followed the PASRR company’s guidelines.
A resident with moderately impaired cognition, heart failure, hypertension, and an order for apixaban for atrial fibrillation did not have the anticoagulant, its side effects, or monitoring needs addressed on the comprehensive care plan. The DON confirmed the omission, and the Administrator stated the facility did not have a specific anticoagulant care plan policy.
Failure to Use Gait Belt During Transfer: A resident with moderately impaired cognition, multiple gait and mobility impairments, and a care plan requiring gait belt use for transfers fell when staff assisted him from bed to the bathroom with a walker but without a gait belt. The incident report and staff statements showed the CNA did not use the gait belt because the resident normally walked okay, despite the resident’s fall risk and the facility’s gait belt policy.
Failure to administer oxygen per physician order. A resident with asthma, chronic lung disease, and oxygen therapy needs was ordered 2 L via n/c continuously, but staff observed the oxygen concentrator set at 0.5 L on two occasions. An LPN verified the incorrect setting and the resident stated the oxygen was supposed to be at 2 L. The DON confirmed the order and reported the facility did not have an oxygen therapy policy.
Failure to monitor anticoagulant therapy led to missed Warfarin doses for a resident with atrial fibrillation and a history of venous thrombosis/embolism. The resident’s INR results were faxed to the provider, but no clear follow-up orders were documented, the Warfarin order dropped off the MAR, and staff reported confusion about stop dates and missing clarification orders.
Delay in Starting Ordered Antibiotic: A resident with severe cognitive impairment, neurogenic bladder, obstructive uropathy, and an indwelling catheter developed signs of a UTI, including cloudy urine, suprapubic pain, and functional decline. After the provider ordered Cefadroxil, the antibiotic was not started for more than 2 days because the medication was not obtained from the pharmacy and staff did not use the emergency kit medication that was available.
Repeated QAPI deficiencies remained unresolved across 5 of 9 areas of concern identified in prior surveys, including abuse reporting, comprehensive care planning, professional standards of care, accident hazards/supervision/devices, and the QAPI program/plan disclosure/good faith attempt. The QAPI report described resident-centered care goals and system-focused monitoring, and the Administrator acknowledged the repeat concerns were not fully resolved and that more work remained in QAPI.
Failure to Report Potential Abuse Injury: A resident with severe cognitive impairment, Alzheimer's dementia, and CVA developed an unexplained bruise to the eyebrow area that was not present earlier in the day and could not be explained by the resident. Staff and the Administrator did not report the injury as a potential abuse/unknown-source injury to DIAL, instead completing a Concern Form after a family member said state involvement was unnecessary; the form lacked documentation in the resolution section.
Failure to follow a physician order for toe wound care. A resident with Alzheimer’s disease, stroke, DM, and severe cognitive impairment had an order to cleanse and paint the left foot 2nd and 3rd toes and keep the sock inside out to prevent rubbing. The resident returned from an appointment with instructions to turn socks inside out, but the care plan lacked direction for the toe treatment, and during an observed treatment the RN noted the socks were not inside out as ordered while the ADON was present.
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.
Delayed call light response due to short staffing: Multiple residents reported waiting longer than 15 minutes for call lights to be answered, and call light logs documented response times ranging from 16 to 24 minutes. Residents with BIMS scores ranging from 6 to 15 described delays, and staff, including an LPN and CNA, confirmed the evening shift was short-staffed and unable to answer call lights within the expected timeframe.
A resident's room had a broken bed footboard and a toilet that was out of order for a period of time, with the resident using a commode that remained in the room and was described as embarrassing. Maintenance staff confirmed the toilet issue and said the bed footboard was replaced only after the surveyor identified it as broken; staff were not aware of any audits or scheduled room checks for beds, toilets, or furnishings.
Unnecessary Psychotropic Medication Regimen: A resident with memory impairment, bipolar disorder, schizophrenia, anxiety, worsening confusion, wandering, disrobing, and repeated falls was receiving multiple psychotropic meds, including Haldol, clonazepam, bupropion, and Cogentin. The record showed escalating behaviors, difficulty following directions, and repeated incidents of being found on the floor or in other residents’ rooms, while the chart lacked documentation of a GDR attempt or a clinical rationale for continued high psychotropic use.
Failure to Follow Physician Order for Suprapubic Catheter Type: A resident with MS, neurogenic bladder, and a chronic suprapubic catheter had repeated catheter problems when staff used a silicone catheter instead of the ordered silastic catheter. The resident had no urine output, leakage, blood in the tubing, and the catheter was later found displaced into the vagina/perineal area. Staff and the DON confirmed the physician ordered silastic catheter use, but the facility used silicone.
Failure to assess a resident with a suprapubic catheter when there was no urine output in the drainage bag for 2 days. The resident had neurogenic bladder, MS, DM, and a history of chronic catheter and UTI issues. Staff documented the resident was wet/incontinent, found blood in the tubing, replaced the catheter, and the resident later went to the ED for urinary retention and obstruction of the suprapubic catheter after reporting pain/discomfort.
Failure to provide adequate supervision for a resident at risk for falls. The resident had a BIMS score of 14, no impaired cognitive decisions, and diagnoses including HF, HTN, DM, Parkinson’s disease, anxiety, and depression. The care plan called for assistance with ambulation/transfers, a low bed, an open bedroom door for closer supervision, and walker signage. Despite these interventions, the resident had multiple fall-related incidents, including being found on the floor near the bathroom door, after going to the bathroom, and in front of a recliner; a CNA also witnessed the start of one fall. The DON acknowledged the chart lacked documentation of hourly checks, and the facility had no falls policy.
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 Notify Physician and Wound Center of Wound VAC Hold
Penalty
Summary
The facility failed to notify the physician and the wound center when Resident #2’s wound VAC/negative pressure wound therapy was placed on hold and the prior Dakin’s moist kerlix packing treatment was restarted. Resident #2’s MDS showed a BIMS score of 15, dependence on staff for bed mobility, transfers, and toileting, and diagnoses including a stage 4 sacral pressure ulcer. The care plan directed staff to provide treatment per physician orders, and the wound center discharge instructions directed continuous wound VAC therapy at 125 mm/hg with black foam, with the current Dakin’s treatment to continue until the wound VAC could be placed. The February 2026 TAR documented that the wound VAC was started and then placed on hold, with daily Dakin’s packing restarted. The clinical record lacked documentation that the physician and/or wound center were notified of the hold or the return to the prior treatment. The resident reported that the wound VAC had not been on since the prior Wednesday because the filter was on back order and that the wound was being packed daily, while the DON stated the facility was out of wound VAC canisters and that the wound center was not notified. The wound center RN confirmed the wound center had not been informed that the wound VAC had been put on hold.
Failure to Submit Level 2 PASRR for New Mental Health Diagnoses and Antipsychotic Use
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for one resident with new mental health diagnoses and a new psychotropic medication. The resident’s record showed moderately impaired cognition on the MDS, along with diagnoses of non-Alzheimer’s dementia, depression, bipolar disorder, and post-traumatic stress disorder. The care plan identified use of an antipsychotic medication for bipolar disorder, and the clinical record listed major depressive disorder, bipolar disorder, PTSD, and adjustment disorder with mixed anxiety and depressed mood. The record also showed the resident had been receiving aripiprazole since 1/27/25, and a Level 1 PASRR completed on 1/22/25 documented anxiety and depression/depressive disorder with antidepressant and antianxiety medications. No additional PASRR evaluations were found after that assessment, and the record did not show a Level 2 PASRR submission after the new bipolar diagnosis and the addition of the antipsychotic medication. The Social Worker stated she submitted a new PASRR on 2/17/26 and that it came back for a Level 2 review onsite, and she reported nursing was supposed to notify her when there was a new mental health diagnosis or psychotropic medication. The Administrator stated the facility did not have a specific PASRR policy and followed the PASRR company’s guidelines.
Failure to Resubmit PASRR Level II Evaluation
Penalty
Summary
The facility failed to resubmit a PASRR Level II evaluation for one resident with a diagnosis of schizophrenia and a BIMS score of 11, indicating moderate cognitive impairment. The resident’s clinical record showed a Notice PASRR Level II Outcome with a short-term, time-limited approval ending on 1/29/26, but there was no evidence that a new Level II evaluation was resubmitted after that end date. During interview, Social Services staff stated the date to resubmit the PASRR was missed and that the PASRR was not resubmitted until 2/18/26, when it was returned queued for review. The Administrator stated the facility did not have a specific PASRR policy and followed the PASRR company’s guidelines.
Care Plan Did Not Address Anticoagulant Medication
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #3 that addressed the resident’s anticoagulant medication and related monitoring needs. Resident #3’s MDS dated 12/10/25 identified a BIMS score of 12, indicating moderately impaired cognition, and documented diagnoses of heart failure and hypertension, along with receipt of an anticoagulant in the last 7 days. A physician order dated 5/19/25 directed apixaban (Eliquis) 2.5 mg by mouth twice daily for atrial fibrillation. Review of the resident’s care plan with a target date of 3/12/26 showed that the anticoagulant medication, its potential side effects, and what to monitor for while taking the high-risk medication were not addressed on the comprehensive care plan. On 2/17/26, the DON verified that the care plan did not address the anticoagulant medication and stated that it should. On 2/18/26, the Administrator reported the facility did not have a specific care plan policy related to anticoagulants and expected the medication to be added at the next care plan review.
Failure to Use Gait Belt During Transfer
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent an accident and injury for Resident #54, who had a BIMS score of 11 indicating moderately impaired cognition and required partial to moderate assistance for all transfers. The resident’s MDS also listed seizure disorder, dislocation of the right hip prosthesis, muscle wasting and atrophy of the right thigh, ataxic gait, weakness, and other abnormalities of gait and mobility. The care plan identified that the resident required assistance with ADLs, used a gait belt with transfers, and had a fall risk with a goal to utilize transfers with a gait belt. The incident report documented that staff assisted Resident #54 from the bed to the bathroom using a walker but without a gait belt, and the resident reported that his legs gave out while walking. A progress note stated a staff member assisted the resident to the floor during the transfer and told the nurse that a gait belt was not used because the resident normally walked okay for them. The LPN reported that the CNA did not use a gait belt and that she verbally educated the CNA on gait belt use, while the DON stated staff were expected to use a gait belt with transfers and ambulation. The facility policy titled Gait Belt stated its purpose was to safely and effectively transfer or ambulate a resident.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
The facility failed to administer oxygen according to physician orders for Resident #24, who had a BIMS score of 15 and diagnoses of asthma and chronic lung disease, with oxygen therapy documented in the MDS. The care plan identified a risk for ineffective breathing patterns related to chronic respiratory failure, emphysema, and asthma and directed staff to administer oxygen per order. A physician order dated 7/3/25 directed oxygen at 2 liters per nasal cannula continuously every shift for bronchiectasis and asthma, but on 2/16/26 and again on 2/17/26 the resident was observed with the oxygen concentrator set at 0.5 liters per nasal cannula. An LPN verified the concentrator setting at 0.5 liters and stated she wondered if it had been bumped and not noticed. During the observation, the resident stated her oxygen was supposed to be set at 2 liters. The DON later verified the order for 2 liters continuously and stated she would expect the physician order to be followed; she also reported the facility did not have a policy on oxygen therapy.
Failure to Monitor Warfarin Orders and INR Results
Penalty
Summary
The facility failed to ensure adequate monitoring of a resident’s anticoagulant therapy and lab orders for Resident #2, who had a BIMS score of 15 and diagnoses including atrial fibrillation and a personal history of venous thrombosis and embolism. The care plan identified Warfarin and Lovenox use related to venous thrombosis and embolism and directed staff to administer the medications per order. A progress note on 1/21/26 documented new orders to increase Warfarin to 5 mg daily and recheck INR on 1/26/26, and a physician note on 1/22/26 stated the resident had restarted Warfarin and Lovenox would be discontinued once therapeutic. The record showed the INR result on 1/26/26 was 1.6 and was faxed to the provider, but there was no provider response documented on 1/26/26 or 1/27/26. The resident’s Warfarin order then dropped off the MAR, and the last dose had been given on 1/25/25, resulting in a missed dose on 1/27/26. Later, an INR result of 1.5 dated 2/9/26 was signed by the provider without directions for Warfarin or the next INR check, and on 2/18/26 the resident again had no active Warfarin order and missed a dose on 2/17/26. Staff interviews documented confusion about stop dates on the MAR, lack of clarification orders from the provider, and that the Warfarin order had fallen off the MAR based on the stop date entered.
Delay in Starting Ordered Antibiotic
Penalty
Summary
The facility failed to ensure a resident with severe cognitive impairment, neurogenic bladder, obstructive uropathy, and an indwelling catheter received a prescribed antibiotic in a timely manner for a urinary tract infection. After the resident developed cloudy, dark yellow urine with thick white mucous-like sediment, suprapubic pain with palpation, and a functional decline in ADLs, the facility notified the provider and obtained a urinalysis order. Abnormal UA results were documented the same day, and the provider then ordered Cefadroxil 500 mg twice daily for 7 days for UTI treatment. Although the antibiotic order was received, the medication was not started until the evening of 1/5/26, more than 2 days after the order was written on 1/2/26. The record showed the facility notified the on-call provider because the antibiotic had not been received from the pharmacy, and the provider instructed staff to contact the pharmacy. The pharmacy was closed and had no emergency number available to the nurse at that time, and the pharmacy later reported it had just received the order and would send the medication in the evening. The DON later reported the facility had an emergency pharmacy number and that the antibiotic was available in the emergency kit, but staff did not remove it from the kit.
Repeated QAPI Deficiencies Not Fully Resolved
Penalty
Summary
The facility failed to correct its own deficiencies in 5 of 9 areas of concern identified across prior surveys within the past year. The repeated concerns included reporting of alleged violations of abuse, developing and implementing a comprehensive care plan, services provided meeting professional standards, being free of accident hazards/supervision/devices, and the QAPI program/plan, disclosure/good faith attempt. The facility reported a census of 55 residents, and the QAPI report reviewed on December 10, 2025 described a mission focused on resident-centered healthcare services, excellence in clinical care, and caregiver engagement and empowerment. The QAPI guiding principles stated that outcomes are directly related to quality of care and quality of life, that the program focuses on systems and processes, and that the organization sets goals and measures progress toward those goals. During an interview on 2/19/26 at 10:55 AM, the Administrator acknowledged the repeated concerns and stated they were not fully resolved, while also saying the facility was continually working on them and building its team. The Administrator further stated there was more work to do in QAPI to address the repeat concerns.
Failure to Report Potential Abuse Injury
Penalty
Summary
The facility failed to report an allegation of potential abuse to DIAL for one resident reviewed. The resident had severe cognitive impairment with a BIMS score of 4 and diagnoses including Alzheimer's dementia and a cerebral vascular accident. The care plan indicated the resident required staff assistance with all ADLs. On 2/3/26 at 1:44 PM, staff observed a bruise to the resident's right eyebrow area that had not been present during the skin assessment completed that morning, and the resident was unable to explain how or when it occurred. The CNA reported the bruise had not been there earlier when cares were completed. The facility policy titled, Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation, stated the Administrator is responsible for investigating and reporting alleged or suspected abuse regardless of the source of concern, and defined an injury of unknown source as one that was not observed by another person or could not be explained by the patient and is suspicious because of the extent or location of the injury. During interview, the Administrator stated the bruise was not reported to DIAL because a family member said it was unnecessary and did not want the state involved. The Administrator said that after speaking with corporate personnel, the facility completed a Concern Form instead of notifying DIAL, and the Concern Form lacked documentation in the Resolution of Concern section.
Failure to Follow Wound Treatment Order for Toe Care
Penalty
Summary
The facility failed to follow physician orders related to wound treatment for Resident #45, who had diagnoses of Alzheimer's disease, stroke, and diabetes mellitus and a BIMS score of 4 indicating severe cognitive impairment. The physician order effective 2/11/26 directed staff to cleanse the left foot 2nd and 3rd toes with normal saline, paint with iodine, allow it to dry, and ensure the sock was inside out to prevent rubbing twice daily. The resident returned from an appointment on 2/12/26 with papers directing that socks be turned inside out to avoid irritation to the toes, but the care plan lacked direction related to the treatment of the left foot toes. During observation on 2/18/26, Staff A, RN, completed the toe treatment and noted the resident's socks were not inside out as ordered; Staff B, ADON, was present and acknowledged the socks were not inside out and directed Staff A to ensure they were reapplied inside out.
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.
Delayed Call Light Response Due to Short Staffing
Penalty
Summary
The facility failed to provide nursing staff to assure resident safety by not responding to call lights in a timely manner for 4 of 4 residents reviewed. Resident #1 had a BIMS score of 6, indicating cognitive impairment, and resided in room D17. The resident stated the facility was short-staffed on the evening shift and reported waiting longer than 15 minutes for the call light to be answered. The Past Call Report for room D17 documented a call light activation on 9/28/25 with an elapsed response time of 18 minutes. Resident #3 had a BIMS score of 15 and resided in room D23, and stated that the call light took longer than 15 minutes to be answered. The Past Call Report for room D23 documented a 20-minute response time on 9/28/25. Resident #4 had a BIMS score of 14 and resided in room C14; the Past Call Report documented response times of 22 minutes on 9/26/25, 22 minutes on 9/27/25, and 24 minutes on 9/29/25. Resident #6 had a BIMS score of 15 and resided in room B42, stated that call lights took longer than 15 minutes to be answered, and the Past Call Report documented response times of 16 minutes on 9/27/25 and 21 minutes on 9/29/25. Staff interviews confirmed call lights were taking longer than 15 minutes to answer on the evening shift due to short staffing, and the Administrator and DON acknowledged that call lights were over the 15-minute expectation.
Broken Bed Footboard and Unmaintained Toilet
Penalty
Summary
The facility failed to provide a resident with a comfortable homelike environment by not maintaining a bed and toilet in functioning order. Observation on 9/29/25 and again on 9/30/25 showed the footboard in Resident #1's room split in half, with silver brackets placed on the inside holding it together. Resident #1 stated the footboard had been broken since admission in July and said they were afraid to sleep in the bed because of the broken footboard and falling out of bed. Resident #1 also reported that the bathroom toilet had not worked for a couple of days and that a commode had to be used, which the resident said was embarrassing because the commode remained in the room. A work order documented that the toilet was broken and a new toilet was in progress, and a receipt showed a toilet was purchased. Maintenance staff confirmed the toilet had been broken for a couple of days about a month earlier and said a work order had been completed. Staff also stated the footboard was replaced only after the surveyor identified it as broken and were not aware of any audits or scheduled room checks for beds, toilets, or furnishings.
Unnecessary Psychotropic Medication Regimen
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from unnecessary psychotropic medications. The resident’s MDS documented short-term memory impairment, moderately impaired decision-making, substantial to maximal assistance with ADLs, behavioral symptoms, and diagnoses including anxiety, bipolar disorder, and schizophrenia. The record also showed use of antipsychotic, antianxiety, and antidepressant medications during the look-back period. Clinical notes documented a pattern of worsening confusion, wandering, disrobing, inability to follow directions, staring spells, and repeated falls over the course of the record. The resident was found wandering into other residents’ rooms, sitting in other residents’ beds, pacing, rummaging through items, and at times appearing unable to respond when spoken to. Multiple incident reports documented falls in hallways, bathrooms, and near the nurses’ station, including episodes where the resident was found on the floor, on hands and knees, or scooting on the floor. Staff also documented that the resident was increasingly difficult to redirect and required extensive cueing and physical assistance for routine tasks such as sitting, dressing, showering, and ambulation. A psychiatric evaluation was requested because of increased behaviors, confusion, falls, impulsiveness, and difficulty following simple directions. The evaluation resulted in increased Haldol and increased bupropion, with continued Cogentin. Later notes documented continued confusion, inability to follow commands, and additional falls, along with changes to clonazepam because of falls. The pharmacy review requested follow-up on continued need for Haldol and noted that if dose reduction was not in the resident’s best interest, a patient-specific clinical rationale should be documented. The DON 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 they contributed to the change in condition or falls.
Failure to Follow Physician Order for Suprapubic Catheter Type
Penalty
Summary
The facility failed to follow physician orders for Resident #3, who had a history of multiple sclerosis, neurogenic bladder, diabetes mellitus, hypertension, and a chronic suprapubic catheter. The resident’s care plan directed staff to change the catheter per order and use a suprapubic catheter with ongoing monitoring for complications. The medication review signed by the primary care provider on 7/2/25 instructed that the suprapubic catheter be changed every 14 days with a silastic urinary catheter. On 7/3/25, staff documented that the resident had no output in the catheter drainage bag for 2 days and was very wet/incontinent of urine. The nurse attempted to remove the catheter after finding blood in the tubing and met resistance, then removed it and placed a new catheter. Shortly afterward, the CNA reported that the catheter was coming out of the vagina, and the nurse documented that the catheter was sticking out of the perineal area. The nurse contacted the urology clinic and was told to monitor urine output and seek emergency care if the resident developed fever, moderate bleeding, or significant pain. Subsequent records showed continued catheter problems, including very little output, a drenched brief, transport to the ER, and later documentation that the resident’s catheter had been changed using a silicone catheter. The resident later reported that the nurse had attempted to insert the silicone catheter multiple times and that the end of the catheter caught. Staff interviews confirmed that the physician ordered a silastic catheter for the resident and that the catheter used was silicone rather than silastic.
Failure to Assess No Urinary Output in Catheter Bag
Penalty
Summary
The facility failed to assess a resident with an indwelling suprapubic catheter when there was no urinary output in the catheter bag for two days. Resident #3 had diagnoses including neurogenic bladder, diabetes mellitus, multiple sclerosis, depression, pneumonia, and sepsis, and the care plan identified chronic catheter and urinary tract infection concerns with interventions to encourage fluids, administer medications as ordered, and observe for signs and symptoms of UTI and pain or discomfort related to catheter use. The documentation survey report showed no urinary output on multiple shifts across several days. On 7/3/25, staff documented that the CNA reported the resident had not had any output in the catheter drainage bag for the last 2 days and had been very wet/incontinent of urine. The RN noted dark red blood in the tubing, deflated the balloon, and placed a new catheter with only a small amount of urine obtained. The next day, the resident had very little output and was transported to the Emergency Department, where the after-visit summary listed urinary retention and obstruction of the suprapubic catheter. The resident later stated she had no urinary output for 2 days and had pain/discomfort and requested to go to the ER, and the RN and DON both acknowledged that no urinary output for 2 days had occurred.
Failure to Provide Adequate Supervision for a Resident at Risk for Falls
Penalty
Summary
The facility failed to provide adequate nursing supervision for one resident who was identified as being at risk for falls related to gait imbalance. The resident’s MDS documented a BIMS score of 14, indicating no impaired cognitive decisions, and noted diagnoses including heart failure, hypertension, diabetes mellitus, Parkinson’s disease, anxiety, and depression. The care plan directed staff to assist with ambulation and transfers as needed, keep the bed in low position, leave the bedroom door open for closer supervision, and place signage on the walker to remind the resident to use the assistive device and call for assistance. The resident experienced multiple falls or fall-related incidents while in the facility. One incident report described the resident being found sitting on the floor in front of the bathroom door with the scooter on his left side after a CNA witnessed him lowering himself to the floor. Another report stated the resident was found on the floor after saying he had gone to the bathroom and his knee gave out. Additional incident reports described the resident found on the floor in front of a recliner and another event in which a CNA witnessed the start of a fall but could not reach the resident in time. The record included references to hourly checks and leaving the room door open for closer observation, but the DON acknowledged the clinical record lacked documentation that hourly checks were completed, and the facility did not have a policy on falls.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
| Grandview Healthcare Center | 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 July 2026) and official state health department websites.