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-stay | 3 / 1 of 5 |
Staffing
| Total nurse staffing | 3.71386 hours per resident per day |
|---|---|
| Registered nurses | 0.78158 hours per resident per day |
| Weekend total | 3.28429 hours per resident per day |
| Nursing staff turnover | 53.6% (registered nurses 42.9%) |
| Administrators who left | 0 |
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.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 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
| Date | Penalty | Amount |
|---|---|---|
| 2024-12-04 | Fine | $33,540 |
| 2023-11-06 | Fine | $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.
| Name | Role | Share | Since |
|---|---|---|---|
| Cascade Capital Holdings LLC Organization | adp of the snf | — | 2024-08-15 |
| Cascade Capital Partners LLC Organization | adp of the snf | — | 2024-08-15 |
| Ccg Gorgona LLC Organization | adp of the snf | — | 2024-08-15 |
| Gorgona Holdco LLC Organization | adp of the snf | — | 2024-08-15 |
| Gorgona Propco Holdings LLC Organization | adp of the snf | — | 2024-08-15 |
| Gorgona Sub Holdco LLC Organization | adp of the snf | — | 2024-08-15 |
| Gpn Family Trust U/A/D 4/28/08 Organization | adp of the snf | — | 2025-03-03 |
| Legacy Healthcare Financial Services LLC Organization | adp of the snf | — | 2024-08-15 |
| Mn8 Rh Holdco LLC Organization | adp of the snf | — | 2024-08-15 |
| Oakway Operations LLC Organization | adp of the snf | — | 2025-03-03 |
| Webster City Ia Property Holdings, LLC Organization | adp of the snf | — | 2024-08-15 |
| Iowa Portfolio Opco Holdings LLC Organization | direct ownership interest | — | 2024-08-15 |
| Doros Generation Trust U/A/D 1/3/12 Organization | indirect ownership interest | — | 2024-08-15 |
| Gpn Family Trust U/A/D 4/28/08 Organization | indirect ownership interest | — | 2024-08-15 |
| Oakway Operations LLC Organization | indirect ownership interest | — | 2024-08-15 |
| Beasley, Karla Individual | adp of the snf | — | 2024-08-15 |
| Behounek, Linsey Individual | adp of the snf | — | 2024-08-15 |
| Borcherding, Jenny Individual | adp of the snf | — | 2024-08-15 |
| Burken, Sheri Individual | adp of the snf | — | 2024-08-15 |
| Friedenberg, Laura Individual | adp of the snf | — | 2024-08-15 |
| Hassebrock, Megan Individual | adp of the snf | — | 2024-08-15 |
| Hedberg, Jennifer Individual | adp of the snf | — | 2024-08-15 |
| Heitland, Ashley Individual | adp of the snf | — | 2025-01-01 |
| Heying, Larina Individual | adp of the snf | — | 2024-08-15 |
| Houston, Mindy Individual | adp of the snf | — | 2024-08-15 |
| Jaeger, Krystle Individual | adp of the snf | — | 2024-08-15 |
| Larson, Melissa Individual | adp of the snf | — | 2024-08-15 |
| Mcclure, Dorothy Individual | adp of the snf | — | 2024-08-15 |
| Otterbeck, Patricia Individual | adp of the snf | — | 2024-08-15 |
| Rajchenbach, Chaim Individual | adp of the snf | — | 2024-08-15 |
| Shabat, Menachem Individual | adp of the snf | — | 2024-08-15 |
| Shear, Kiley Individual | adp of the snf | — | 2024-08-15 |
| Van Veghel, Elizabeth Individual | adp of the snf | — | 2024-08-15 |
| Wierschem, Bobbie Individual | adp of the snf | — | 2024-08-15 |
| Shabat, Menachem Individual | corporate officer | — | 2024-08-15 |
| Beasley, Karla Individual | operational/managerial control | — | 2024-08-15 |
| Behounek, Linsey Individual | operational/managerial control | — | 2024-08-15 |
| Borcherding, Jenny Individual | operational/managerial control | — | 2024-08-15 |
| Burken, Sheri Individual | operational/managerial control | — | 2024-08-15 |
| Friedenberg, Laura Individual | operational/managerial control | — | 2024-08-15 |
| Hassebrock, Megan Individual | operational/managerial control | — | 2024-08-15 |
| Hedberg, Jennifer Individual | operational/managerial control | — | 2024-08-15 |
| Heitland, Ashley Individual | operational/managerial control | — | 2025-01-01 |
| Heying, Larina Individual | operational/managerial control | — | 2024-08-15 |
| Houston, Mindy Individual | operational/managerial control | — | 2024-08-15 |
| Jaeger, Krystle Individual | operational/managerial control | — | 2024-08-15 |
| Larson, Melissa Individual | operational/managerial control | — | 2024-08-15 |
| Mcclure, Dorothy Individual | operational/managerial control | — | 2024-08-15 |
| Otterbeck, Patricia Individual | operational/managerial control | — | 2024-08-15 |
| Rajchenbach, Chaim Individual | operational/managerial control | — | 2024-08-15 |
| Shabat, Menachem Individual | operational/managerial control | — | 2024-08-15 |
| Shear, Kiley Individual | operational/managerial control | — | 2024-08-15 |
| Van Veghel, Elizabeth Individual | operational/managerial control | — | 2024-08-15 |
| Wierschem, Bobbie Individual | operational/managerial control | — | 2024-08-15 |
| Friedman, Brian Individual | trustee of the snf | — | 2021-01-03 |
| Rajchenbach, Avrum Individual | trustee of the snf | — | 2008-04-28 |
| Rajchenbach, Rivka Individual | trustee of the snf | — | 2008-04-28 |
| Shabat, Ahuva Individual | trustee of the snf | — | 2012-01-03 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Southfield Wellness Community.
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.