Southfield Wellness Community

Inspectors wroteBased on clinical record review, staff interviews, camera/video footage review and policy review, the facility failed to provide adequate supervision and operational alarm safeguards to prevent the elopement for 1 of 1 resident reviewed (Resident #7). On 7/17/26 at 3:45 PM, Resident #7 exited the building unattended. At 3:46 PM, Staff F, Dietary Staff member entered the lobby and shut off both the door alarm and wander guard alarm (across 2 separate keypads) without investigating the cause or checking the exit. Another resident (Resident #12) asked Staff G, Certified Medication Aide (CMA) if she was going to get Resident #7 who went outside. At 3:50 PM, Staff G, CMA asked staff via walkie-talkie if anyone saw Resident #7. Staff G, CMA retrieved Resident #7 from the parking lot of the facility at 3:52 PM.The facility sits at the end of a residential road, 0.1 miles (approx. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure staff monitored weight loss, followed Dietitian recommendations, and notified the Physician of significant weight loss for 1 of 6 residents reviewed (Resident #1) for weight loss. The facility reported a census of 56 residents.

Inspectors wroteBased on observations, resident interviews, facility records review, staff interviews and policy review, the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility (Residents #8, #10 and #11). The facility reported a census of 56 residents.

Inspectors wroteBased on diet orders, staff interviews, clinical record review, and facility policy review the facility failed to serve the appropriate therapeutic diet to meet resident's needs according to their diet order for 1 of 6 residents reviewed (Resident #5). The facility reported a census of 56 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff accurately documented meal intakes in the Electronic Medical Record (EMR) for 1 of 11 residents reviewed (Resident #6). The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review, staff interviews, and wound center interview, the facility failed to notify the Physician when a wound VAC, or negative pressure wound therapy (NPWT) (device that uses gentle suction to promote healing in chronic or acute wound) was placed on hold and a previous treatment restarted for 1 of 2 residents reviewed (Resident #2) for pressure ulcers. The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to report an allegation of potential abuse to the Department of Inspections, Appeals and Licensing (DIAL) for 1 of 14 residents reviewed (Resident #45). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis and start of new psychotropic medications (Resident #4). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to resubmit a Preadmission and Resident Review (PASRR) evaluation as required for 1 of 2 residents reviewed for PASSR (Resident #35). The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to develop a care plan to address risk factors and interventions for 1 out of 14 residents (Resident #3) reviewed for comprehensive care plans. The facility reported a census of 55 residents.

Inspectors wroteBased on observation, clinical record review and staff interviews, the facility failed to follow physician orders related to a wound intervention for 1 of 5 residents reviewed for skin conditions (Resident #45). The facility reports a census of 55 residents.

Inspectors wroteBased on clinical record reviews, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 2 residents reviewed (Resident #54) for falls. The facility reported a census of 55 residents.

Inspectors wroteBased on observations, record review, staff interviews,and resident interview the facility failed to administer oxygen according to physician orders for 1 of 1 resident reviewed (Resident #24) for respiratory services. The facility reported a census of 55 residents. Findings Include: The Minimum Data Set (MDS) assessment for Resident #24 dated 1/16/26 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS included diagnoses of asthma and chronic lung disease. The MDS documented Resident #24 was on oxygen therapy while a resident at the facility. The Care Plan with a target date 4/19/26 revealed Resident #24 had a risk for ineffective breathing patterns related to chronic respiratory failure, emphysema and asthma. The care plan directed to administer oxygen per order. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure adequate monitoring of a resident's lab orders to ensure the resident had the correct thickness of their blood to prevent blood clots for 1 of 1 resident reviewed (Resident #2) for blood thinners. Due to the facility's inadequate monitoring of Resident #2's blood work, the physician didn't order a new dose of blood thinner, resulting in them missing a dose of their blood thinner. The facility reported a census of 55 residents.

Inspectors wroteBased on interviews and clinical record review, the facility failed to start an antibiotic for more than 2 days after a resident received the physician's order for a resident with a urinary tract infection for 1 of 5 residents reviewed (Resident #33) for infection. The facility reported a census of 55.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past surveys, and staff interview, the facility failed to correct their own deficiencies for 5 of 9 areas of concern. The facility reported a census of 55 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews, and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 57 residents.

Inspectors wroteBased on the facility investigation, dignity policy/procedure review, resident and staff interviews, the facility failed to provide personal care to a resident incontinent of stool in a timely manner that promoted their dignity and quality of life for 1 out of 4 residents reviewed. (Resident #1). The facility identified a census of 56 residents.

Inspectors wroteBased on electronic health records (EHR), document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 4 residents reviewed (Residents #1, #3, #4, and #6). The facility reported a census of 56 residents.

Inspectors wroteBased on observations, resident, and staff interviews the facility failed to provide the residents with a comfortable homelike environment by failing to keep a resident bed in functioning order and the toilet properly maintained. The facility reported a census of 56 residents.

Inspectors wroteBased on clinical document review, staff interview, the facility failed to ensure that each resident's medication regimen is free from unnecessary medications for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review, policy review, resident and staff interviews, the facility failed to provide a professional standard of quality by not following physician orders for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 56 residents.

Inspectors wroteBased on observation, clinical record review, staff and resident interview, the facility failed to assess a resident that had no urinary output in their catheter bag for two days for which resulted in the resident going to the Emergency Department with discomfort (Resident #3) for 1 of 3 resident reviewed. The facility identified a census of 56 residents.

Inspectors wroteBased on clinical document review, resident and staff interview, the facility failed to provide adequate nursing supervision for 1 of 3 residents (Resident #4) reviewed. The facility reported a census of 56 residents.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past surveys, and staff interviews, the facility failed to correct their own deficiencies for 7 of 12 areas of concern. The facility reported a census of 54 residents.

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

Inspectors wroteBased on clinical record review, resident interview, staff interview and policy review, the facility failed to provide resident bathing to maintain good personal hygiene and personal choice for residents unable to carry out the activity of daily living (ADL) independently, for four of four residents reviewed (#6, #24, #27 and #48). The facility reported a census of 54 residents.

Inspectors wroteBased on resident interviews, staff interview and policy review, the facility failed to provide care for 1 out of 21 residents reviewed (Resident #24) in a manner to promote dignity and respect. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to develop a Care Plan to address risk factors and interventions for 1 of 21 residents reviewed (Resident #25) for comprehensive Care Plans. The facility reported a census of 54 residents.

Inspectors wroteBased on observations, record review, resident and staff interviews and policy review, the facility failed to provide restorative care for 2 of 2 residents reviewed (Residents #43 and #46). The facility failed to initiate a restorative program for Resident #43 for 18 days after the Physical Therapist (PT) recommended restorative care. In addition, they failed to provide restorative care as (PT) recommended for Resident #46. The facility reported a census of 54 residents.

Inspectors wrote3. Resident #27's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, anemia, hypertension, hyperlipidemia (elevated cholesterol levels increasing the risk for stroke or heart attacks) and paraplegia (the loss or impairment of motor and sensory functions in the lower half of the body). The MDS identified Resident #27 received a diuretic during the lookback period. The Care Plan Focus with a target date of [DATE], indicated Resident #27 had a risk for altered cardiovascular functioning related to hypertension. The Interventions directed the following: a. Monitor vital signs, weight and labs as ordered. b. Knee high TED hose (specialized stocking to prevent blood clots). [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 2 residents reviewed (Resident #20) for falls. The facility failed to complete a thorough root cause analysis and implement a fall intervention after a fall occurred. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide dialysis care to meet the needs of a resident for 1 of 1 residents reviewed (Resident #34). The facility failed to notify the primary care physician (PCP) of weight gain according to the parameters ordered by the PCP. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure the Physician responded promptly to a notification of abnormal laboratory results and chest x ray results for 1 of 21 residents (Resident #55) reviewed. See F684 for additional information regarding Resident #55. The facility reported a census of 54 residents.

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

Inspectors wroteBased on clinical record review, resident and staff interviews and policy review, the facility failed to adequately trained staff to perform a treatment for 1 of 1 resident reviewed (Resident #6). The facility failed to have a nurse flush Resident #6's catheter as ordered. Instead of the nurse, a Certified Nursing Aide (CNA) the irrigated/flushed Resident #6's catheter. The facility reported a census of 54 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to routinely assess and provide interventions for retracting the foreskin of the penis and returning to its original position for 1 out of 3 residents reviewed (Resident #2). Resident #2 required intervention at the Urology Clinic to reduce paraphimosis (foreskin pulled back but unable to return to its original position over the head, or glans, of the penis) on 3 different occasions. This facility reported a census of 52 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow standards for bladder care and services for 2 out of 3 residents reviewed (Residents #1 and #2). Resident #2 had a voiding trial (trial to see if resident could go without a catheter to drain the urine from his bladder) without measuring output or documenting his output for 1 shift. Resident #2 couldn't urinate on a separate shift and had over 1 liter of urine drained from his bladder. Resident #2 had urethral erosion (tissue breakdown around the urinary meatus, opening at the end of the penis) from a Urinary catheter (tube placed in the urethra to drain urine out of the bladder). The facility failed to ensure Resident #2 wore a secure device to hold the catheter in place and to prevent pulling on the catheter. The facility failed to provide timely incontinence care to Resident #1. [...]

Inspectors wroteBased on clinical record reviews, staff interviews, family interview, facility records, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 4 residents reviewed (Residents #1). The facility failed to follow physician orders to administer the correct dose of an antipsychotic medication for 7 days (9/20/24 to 9/27/24). The facility reported a census of 52 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to implement treatment orders for pressure sores for 2 of 3 residents reviewed (Residents #307 and #39). In addition, the facility failed to identify a new skin injury for 1 of 3 residents (Resident #307). Resident #307 admitted to the facility on [DATE] with 2 skin injuries but the facility failed to get him treatment orders until 10/30/23. On 11/1/23 staff found Resident #307 with 2 additional areas of concern. Resident #39 had a chronic ulcer on his sacrum and saw a wound specialist on 10/25/23. The recommended treatment changes did not get implemented until 10/30/23.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep residents safe from accidents and hazards for 4 of 4 residents reviewed (Resident #7, #28, #1, and #11). Staff failed to use a gait belt or ensure proper footwear use when transferring Resident #7. Resident #7 fell on her way to the bathroom and sustained a major injury. After Resident #28 fell, the staff failed to complete neurological assessments. During an observation of a transfer of Resident #1, staff failed to use a gait belt. After Resident #11 sustained a foot injury while off campus, the facility failed to complete an incident report.

Inspectors wroteBased on observation, resident, family, and staff interviews the facility failed to answer call lights in a timely manner for 4 of 4 residents reviewed (Residents #11, #25, #12 and #7).

Inspectors wroteBased on observation, staff interview, facility documentation, and policy review, the facility failed to ensure staff used proper hand sanitizing to prevent or spread infection. The facility also failed to act on resident's personal refrigerators that were out of safe temperature ranges for storing food. The facility reported a census of 55 residents.

Inspectors wroteBased on facility record review and staff interviews, the facility failed to provide satisfactory evidence that they identified their own high risk, high volume, and problem-prone quality deficiencies, and made a good faith attempt to correct them. The facility reported a census of 55 residents.

Inspectors wroteBased on personnel file reviews, facility policy review, and staff interview, the facility failed to provide dependent adult abuse recertification training within 3 years for 1 of 5 employees reviewed (Staff B). The facility identified a census of 55 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to notify the physician of significant weight gains for 1 of 2 residents reviewed (Resident #38).

Inspectors wroteBased on interview, staff file review and policy review the facility failed to report a potential abuse to the surveying agency for 1 of 3 residents (Resident #308). Staff reported to the administration that Staff I, Certified Nurse Aide (CNA), pushed Resident #308 back into a chair in a rough manner. A video recording contained the interaction and the personal file contained a counseling note. The facility did not report the incident to the proper authorities.

Inspectors wroteBased on interview, staff file review and policy review the facility failed to thoroughly investigate a potential abuse situation for 1 of 1 resident reviewed (Resident #308). The staff reported to the Administration that Staff I, Certified Nurse Aide (CNA) pushed Resident #308 into a chair in a forceful manner. A video recording contained the interaction and the facility counseled Staff I.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to send a copy of a notice of transfer to a representative of the Office of the State Long Term Care Ombudsman for 3 of 3 residents reviewed (Resident #4, #49, and #38).

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to provide a bed hold notice for 2 or 3 residents reviewed (Residents #4 and #49).

Inspectors wroteBased on clinical record review staff interview, the facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for 2 of 3 reviewed (Residents #4 and #11).

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to develop a Care Plan that addressed risk factors and interventions related to type 2 diabetes for 1 out of 20 residents (Resident #25) reviewed for comprehensive Care Plans.

Inspectors wroteBased on clinical record, and staff interview, the facility failed to update care plans with fall interventions and feeding assistance needs for 2 of 6 residents reviewed (Residents #1 and #5). The facility reported a census of 55 residents.

Inspectors wrote3. Resident #49's MDS assessment dated [DATE] listed a readmission date of 7/23/23 from an acute hospital. The MDS identified a BIMS score of 14, indicating intact cognition. The assessment reflected that Resident #49 had impaired range of motion (ROM) to one side of the upper extremity. The hospital Transfer/Discharge/Active Orders dated 4/18/23 included an order for continuous use of a splint to his right wrist, hand, remove 3 times a day to complete hygiene cares and check for skin breakdown. Resident #49's October 2023 Treatment Administration Record (TAR) included an order on 5/13/23 for edema glove on in morning (AM) and off at bedtime (HS). On 10/30/23 at 11:54 AM observed Resident #49 in the dining room without an edema glove and/or a splint to his right hand. On 10/30/23 at 4:00 PM witnessed Resident #49 in his room without an edema glove and/or a splint to his right hand. [...]

Inspectors wroteBased on observations, interviews, and chart review the facility failed to offer the use of a toilet on a timely basis to 1 of 3 residents reviewed (Resident #45). An observation revealed Resident #45 sitting in his chair for over 4 hours before someone offered to take him to the toilet.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to reassess 1 of 1 resident reviewed (Resident #11) for electric wheelchair safety after an accident.

Inspectors wroteBased on observations, interview and record review the facility failed to reposition residents to prevent pressure for 2 of 3 residents (Residents #307 and #45). In addition, the facility failed to provide range of motion exercises as recommended for 1 of 1 residents (Resident #12).

Inspectors wrote3. Resident #46's MDS assessment dated [DATE] identified a BIMS score of 15 indicating cognitively intact. Resident #46 ate with set-up help and supervision. The MDS included diagnoses of heart failure, hypertension, and renal insufficiency. Resident #46 received a mechanically altered diet and a therapeutic diet. The Care Plan with a target date of 12/20/23 included a Focus that indicated Resident #46 had nutritional risks related to diabetes mellitus type 2, congestive heart failure, end stage renal disease, and dialysis. He needed a mechanical and therapeutic diet. The Interventions directed the following: a. Encourage him to follow his order for fluid restriction b. Resident #46 would receive a renal diet, mechanical soft texture, regular fluid consistency, and a 1500 cc fluid restriction. c. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide enteral (fluids delivered directly into the stomach) water as ordered for 1 of 2 residents reviewed (Resident #42). Resident #42 required tube feedings and experienced increased vomiting. On 10/27/23 the dietician recommended a decrease in the water flow in his 24-hour tube feedings. An order was entered on 10/30/23 to decrease the fluids with feedings from 25 milliliters (ml) an hour to 20 ml. On 10/30/23, 10/31/23 and 11/1/23 an observation revealed the water flow still set on 25 ml. As of 11/1/23 at 7:00 AM the facility still did implement the order change.

Inspectors wroteBased on record review, staff interviews and policy review the facility failed to do a dialysis assessment or a complete before and/or after dialysis assessment for 2 of 2 residents reviewed (Resident #46 and #38).

Inspectors wroteBased on record review and staff interview, the facility failed to provide adequate monitoring of prophylactic (preventative) antibiotic use for 1 resident reviewed, (Resident #38). The facility notified Resident #38's primary provider. When the primary provider replied that a specialist provided the order, the facility failed to contact the prescribing provider to review the prophylatic order.

Inspectors wroteBased on observation, interview and record review the facility failed to discontinue an as needed (PRN) antipsychotic medication (haloperidol or Haldol) or seen by the provider within 14 days to determine the necessity of the medication for 1 of 5 residents reviewed (Resident #45). The Pharmacist recommended that the physician see Resident #45 still needed the medication, the benefit of the medication, and/or if the medication helped him. The facility failed to implement the recommendation for two months after the pharmacy review.

Inspectors wroteBased on observation and staff interview, the facility failed to wear gloves to remove a used dirty dressing while completing wound care for 1 of 1 resident reviewed (Resident #26).