Nursing Care Index

Southfield Wellness Community

Webster City, Hamilton County, Iowa · CCN 165411 · For-profit (LLC) · part of Legacy Healthcare (89 facilities, chain average 2.9 stars)

CMS rates Southfield Wellness Community 1 of 5 overall as of August 2026. 65 certified beds, 54 residents a day on average. 58 citations on record from the current inspection cycles, 4 involving actual harm; 2 fines totalling $71,897.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★★★☆ 4 of 5
Quality measures★★☆☆☆ 2 of 5
Quality: long-stay / short-stay3 / 1 of 5

Staffing

Total nurse staffing3.71386 hours per resident per day
Registered nurses0.78158 hours per resident per day
Weekend total3.28429 hours per resident per day
Nursing staff turnover53.6% (registered nurses 42.9%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-02-19 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-02-19 Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-16
2026-01-28
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-02-02
2025-12-17
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-16
2025-11-18
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-12-19
2025-11-18
complaint survey
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-19
2025-11-18
complaint survey
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-19
2025-11-18
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-19
2025-11-18
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-19
2025-11-18
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-19
2025-03-03 Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-04-02
2025-03-03 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-04-02
2025-03-03 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-04-02
2025-03-03 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2025-03-03 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2025-03-03 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies · tag F0676
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2025-03-03
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2025-03-03
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2025-03-03 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2025-03-03 Provide or arrange emergency care by a doctor 24 hours a day.
Nursing and Physician Services Deficiencies · tag F0713
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2025-03-03 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2025-03-03 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Nursing and Physician Services Deficiencies · tag F0726
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-02
2024-12-04
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-12-19
2024-12-04
complaint survey
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-12-19
2024-12-04
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-12-19
2023-11-06
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-29
2023-11-06
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-29
2023-11-06
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-12-11
2023-11-06 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-12-11
2023-11-06 Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-12-11
2023-11-06 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0943
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-12-11
2023-11-06 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-29
2023-11-06 Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-29
2023-11-06 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Resident Rights Deficiencies · tag F0625
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06
complaint survey
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06
complaint survey
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06
complaint survey
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11
2023-11-06 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-11

Fines and payment denials

DatePenaltyAmount
2024-12-04Fine$33,540
2023-11-06Fine$38,357

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Cascade Capital Holdings LLC
Organization
adp of the snf2024-08-15
Cascade Capital Partners LLC
Organization
adp of the snf2024-08-15
Ccg Gorgona LLC
Organization
adp of the snf2024-08-15
Gorgona Holdco LLC
Organization
adp of the snf2024-08-15
Gorgona Propco Holdings LLC
Organization
adp of the snf2024-08-15
Gorgona Sub Holdco LLC
Organization
adp of the snf2024-08-15
Gpn Family Trust U/A/D 4/28/08
Organization
adp of the snf2025-03-03
Legacy Healthcare Financial Services LLC
Organization
adp of the snf2024-08-15
Mn8 Rh Holdco LLC
Organization
adp of the snf2024-08-15
Oakway Operations LLC
Organization
adp of the snf2025-03-03
Webster City Ia Property Holdings, LLC
Organization
adp of the snf2024-08-15
Iowa Portfolio Opco Holdings LLC
Organization
direct ownership interest2024-08-15
Doros Generation Trust U/A/D 1/3/12
Organization
indirect ownership interest2024-08-15
Gpn Family Trust U/A/D 4/28/08
Organization
indirect ownership interest2024-08-15
Oakway Operations LLC
Organization
indirect ownership interest2024-08-15
Beasley, Karla
Individual
adp of the snf2024-08-15
Behounek, Linsey
Individual
adp of the snf2024-08-15
Borcherding, Jenny
Individual
adp of the snf2024-08-15
Burken, Sheri
Individual
adp of the snf2024-08-15
Friedenberg, Laura
Individual
adp of the snf2024-08-15
Hassebrock, Megan
Individual
adp of the snf2024-08-15
Hedberg, Jennifer
Individual
adp of the snf2024-08-15
Heitland, Ashley
Individual
adp of the snf2025-01-01
Heying, Larina
Individual
adp of the snf2024-08-15
Houston, Mindy
Individual
adp of the snf2024-08-15
Jaeger, Krystle
Individual
adp of the snf2024-08-15
Larson, Melissa
Individual
adp of the snf2024-08-15
Mcclure, Dorothy
Individual
adp of the snf2024-08-15
Otterbeck, Patricia
Individual
adp of the snf2024-08-15
Rajchenbach, Chaim
Individual
adp of the snf2024-08-15
Shabat, Menachem
Individual
adp of the snf2024-08-15
Shear, Kiley
Individual
adp of the snf2024-08-15
Van Veghel, Elizabeth
Individual
adp of the snf2024-08-15
Wierschem, Bobbie
Individual
adp of the snf2024-08-15
Shabat, Menachem
Individual
corporate officer2024-08-15
Beasley, Karla
Individual
operational/managerial control2024-08-15
Behounek, Linsey
Individual
operational/managerial control2024-08-15
Borcherding, Jenny
Individual
operational/managerial control2024-08-15
Burken, Sheri
Individual
operational/managerial control2024-08-15
Friedenberg, Laura
Individual
operational/managerial control2024-08-15
Hassebrock, Megan
Individual
operational/managerial control2024-08-15
Hedberg, Jennifer
Individual
operational/managerial control2024-08-15
Heitland, Ashley
Individual
operational/managerial control2025-01-01
Heying, Larina
Individual
operational/managerial control2024-08-15
Houston, Mindy
Individual
operational/managerial control2024-08-15
Jaeger, Krystle
Individual
operational/managerial control2024-08-15
Larson, Melissa
Individual
operational/managerial control2024-08-15
Mcclure, Dorothy
Individual
operational/managerial control2024-08-15
Otterbeck, Patricia
Individual
operational/managerial control2024-08-15
Rajchenbach, Chaim
Individual
operational/managerial control2024-08-15
Shabat, Menachem
Individual
operational/managerial control2024-08-15
Shear, Kiley
Individual
operational/managerial control2024-08-15
Van Veghel, Elizabeth
Individual
operational/managerial control2024-08-15
Wierschem, Bobbie
Individual
operational/managerial control2024-08-15
Friedman, Brian
Individual
trustee of the snf2021-01-03
Rajchenbach, Avrum
Individual
trustee of the snf2008-04-28
Rajchenbach, Rivka
Individual
trustee of the snf2008-04-28
Shabat, Ahuva
Individual
trustee of the snf2012-01-03

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Hamilton County.