Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Good Shepherd Health Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, multiple chronic conditions, and a history of falls developed noticeable bruising and swelling on the right hip and thigh area that staff observed over multiple days. CNAs reported the bruising to an LPN, but the nurse did not assess the area when first notified, and no assessment occurred until the resident began expressing pain with transfers and movement. At that point, staff documented a large, multi-colored bruise extending from the upper inner thigh to the buttock and down the posterior thigh, with leg shortening, outward knee rotation, edema, and pain on passive range of motion, despite existing care plan and skin program expectations for prompt assessment and follow-up of skin changes and unusual occurrences.
A resident with Alzheimer’s disease, Parkinson’s disease, depression, and impaired decision-making experienced progressive weight loss while requiring supervision with eating and drinking. The care plan called for staff assistance when the resident was not eating, small frequent meals, house supplements, RD evaluation, and weekly weights, yet clinical notes documented repeated refusals of food, supplements, and assistance, along with episodes of pushing food away and dumping liquids. Despite this, the record lacked evidence of appropriate individualized interventions to address the unintended weight loss, and after an order for 2 liters of water per day with 1:1 assistance, there was no documentation that the ordered fluid intake was consistently provided, contrary to facility policy on managing unintended weight loss.
Bird Aviary Windows Not Kept Free of Bird Feces. The facility failed to keep the windows of 2 bird aviaries free of excessive bird feces between quarterly cleanings. Both the Memory Care and Dining Room aviaries had multiple windows with white bird feces, and the Administrator stated no one cleans or enters the aviaries between the contracted quarterly cleanings unless something urgent arises.
QAA Committee Did Not Include Medical Director at Quarterly Meetings. The facility failed to ensure the Medical Director attended quarterly QAA meetings. QA records showed the Medical Director attended some meetings but was absent from two quarterly meetings, and both the Administrator and DON acknowledged the missed attendance during interview. The 2025 QAPI Plan stated the committee meets with the Medical Director and may meet quarterly instead of bi-monthly or monthly.
Failure to notify a resident's representative before giving a psychotropic medication. A resident with severe cognitive impairment, dementia, diabetes, and respiratory failure was ordered quetiapine PRN for aggression and agitation, and the MAR showed multiple doses were administered. The EHR lacked documentation that the representative was informed of the risks and benefits, treatment alternatives, or other options before administration, and the DON stated the facility did not obtain family consent prior to giving the medication.
Resident property was discarded before the family finished collecting belongings after a resident’s death. A Social Worker misread a note, housekeeping cleaned the room, and several personal items were thrown away, including framed photos, clothing, a wall hanging, and a blanket. The daughter reported the loss, and the facility acknowledged the misunderstanding.
Failure to submit an updated PASRR for a resident with new MH diagnoses. A resident had anxiety, depression, psychotic disorder, later generalized anxiety disorder, dementia with behavioral disturbance, and psychosis, and was also started on quetiapine. The SW stated the last PASRR had been done years earlier and acknowledged a new PASRR should have been completed, while the ADON said the facility had no PASRR policy and followed the guidelines.
A resident with a recent hip repair and severe cognitive impairment experienced an unwitnessed fall, after which he reported increased pain and required more assistance with transfers. Despite ongoing reports of pain and functional decline from CNAs and nurses, the facility delayed sending him for emergency evaluation, instead providing PRN Tylenol and contacting the physician by fax. The resident was only sent to the ER several days later, where he was diagnosed with a new pelvic fracture, hypoxia, and COVID-19. Staff interviews confirmed that the resident's change in condition warranted earlier emergency intervention.
A resident with severe cognitive impairment and a history of combative behavior was physically struck on the hand by a CNA and subjected to derogatory language during an episode of agitation while being assisted to the bathroom. The staff member responded to the resident's aggression with both physical and verbal retaliation, and the incident was not immediately reported. Assessment revealed bruising and redness on the resident's hand and wrist, and facility policy requiring respectful treatment was not followed.
A resident with severe cognitive impairment and multiple medical conditions was struck on the hand by a CNA after an altercation. The incident was witnessed by another CNA, who failed to report the event to facility management within the required 2-hour timeframe, resulting in delayed notification to state authorities as mandated by policy.
A facility failed to transmit an MDS assessment for a resident within the required timeframe. The resident was discharged home, and the MDS assessments completed were not transmitted, although previous assessments had been. A nurse admitted to completing the discharge MDS but not submitting it to CMS. The facility lacked a policy for MDS submissions and followed the RAI Manual, which requires submission within 14 days after completion.
A resident in the facility had multiple instances of abnormal blood pressure readings that were not reassessed as required. The resident's TAR indicated an order for regular blood pressure monitoring, but several low and high readings were not followed up on. An LPN admitted to not rechecking the readings, and the DON confirmed the oversight, acknowledging that the charge nurse and physician should have been informed. The facility's policy on blood pressure measurement was not adhered to in this case.
A resident with cerebral palsy and dementia did not receive necessary palm guards to prevent contractures, despite being provided with them after occupational therapy. Observations showed the resident without the guards, and staff interviews confirmed they had been missing for some time without replacement requests. The facility failed to follow the care plan and maintain communication for the resident's needs.
A resident with moderately impaired cognition and recent fall history had their call light placed eight feet away, contrary to facility policy requiring accessibility. This oversight occurred despite the resident's independence in mobility and resulted in a fall and arm fracture. The DON and Administrator confirmed the expectation for call lights to be within reach.
A resident was catheterized without a medical order by a new RN during orientation, leading to distress for the resident. The RN confused residents and performed the procedure on the wrong individual, resulting in her termination. The facility acknowledged the error and confirmed that catheterization should only occur with a proper order.
The facility did not conduct a comprehensive assessment to determine necessary resources for resident care, failing to evaluate needs such as ADLs, bowel/bladder status, mental abilities, skin integrity, special care, treatments, and medications. The absence of a form in the current EHR system led to this deficiency, as acknowledged by the DON and Administrator.
The facility failed to follow infection control practices during medication administration. A CMA was observed handling medications with bare hands for two residents, contrary to the facility's policy requiring gloves or tools to avoid direct contact. Interviews with LPNs and the DON confirmed that touching pills with bare hands is against the facility's procedures.
A resident with intact cognition and independent mobility fell while getting off a facility van due to the van driver's error in managing the van lift. The resident, who had a history of cancer, hypertension, and malnutrition, experienced wrist pain but declined further medical evaluation.
A resident with multiple medical conditions fell and complained of new rib pain, but the LTC facility delayed sending him to the hospital for over two hours. Despite family concerns, the facility's policy requiring a physician's order for hospital transfers contributed to the delay. The resident was later found to have severe injuries and passed away after being admitted to the ICU.
The facility failed to respond to resident call lights within the regulated 15-minute timeframe, affecting multiple residents. One resident's call light was on for 16 minutes before an LPN entered without addressing the call light, and two CNAs later turned it off without assisting. Another resident's daughter reported delays of up to an hour, leading to self-transfers and soiled clothing. A third resident experienced 45-minute waits, causing pain. These issues occurred across shifts, violating resident rights to timely assistance.
A resident's call light was left unanswered for 16 minutes before an LPN entered the room with a nutritional drink and pain patch. The LPN then displayed unprofessional behavior by speaking in a derogatory tone, rolling her eyes, and making negative facial expressions towards the resident and their family member. The family member reported this behavior as consistent. The facility's Resident Rights form requires treating residents with respect and dignity.
Failure to Timely Assess Extensive Bruising and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and care for a significant bruise on a resident’s right inner/outer thigh and hip area after staff became aware of it. The resident had moderate cognitive impairment with a BIMS score of 11, could understand and be understood by others, and had diagnoses including hypertension, Alzheimer’s disease, anxiety, depression, low back pain, and a history of falls. The resident required total assistance with toileting and substantial to maximal assistance with hygiene and dressing, and had a care plan focus for risk of skin breakdown with interventions including observation of skin with cares and notification of the nurse or provider of concerns. On 2/13/26, CNAs reported noticing purple/green swelling and bruising on the resident’s right hip and under the buttocks, described as noticeable, and another CNA reported it took two staff and a gait belt to transfer the resident and that they noticed a bruise while in the bathroom. On 2/14/26, a CNA stated they told the nurse about the bruises at 8:45 AM, but the LPN later admitted they did not look at the bruise that day, stating it slipped their mind. During this period, the resident reportedly did not show signs of pain on 2/14/26, and no nursing assessment of the bruised area was documented until the following day. On 2/15/26 at 10:40 AM, staff called the nurse to the resident’s bathroom due to the resident’s discomfort when transferring from the toilet to the wheelchair, and a large dark purple bruise was observed extending from the right upper inner thigh to the buttock, with various colors including purple, brownish, and faded yellow, and faint yellow bruising on the left thigh. Later that day, the resident was observed in bed with the right leg appearing shorter than the left, the right knee turned outward, non-pitting edema of the thigh and knee, and pain with gentle passive range of motion. Facility documentation, including a risk management form, health status note, incident notes, and an investigation file, consistently described the extensive bruising and the resident’s pain with movement, and administrative staff acknowledged that the nurse failed to assess the bruise when first alerted on 2/14/26, contrary to expectations and the facility’s skin program, which required use of risk management for identification of skin issues and follow-up observation.
Failure to Implement Interventions for Weight Loss and Hydration
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate interventions to prevent weight loss and ensure sufficient hydration for a cognitively impaired resident with Alzheimer’s disease, Parkinson’s disease, and depression. The resident’s MDS showed short- and long-term memory problems, severely impaired decision-making, and a need for supervision with eating and drinking, with an initial weight of 230 pounds and no documented weight loss at that time. The care plan identified an ADL self-care performance deficit and included interventions such as staff assistance when the resident was not eating, provision of small frequent meals, house supplements as ordered, RD evaluation for diet changes, and weekly weights. Subsequent weight records showed a progressive decline from 234.5 pounds to 217.4 pounds over several weeks, reaching at least a 5% weight loss, while behavior and health status notes documented repeated refusals of food, supplements, and assistance with feeding, as well as episodes of the resident pushing food away, clamping his mouth shut, and dumping liquids on the floor. Despite these documented behaviors and the ongoing weight loss, the clinical record did not show that appropriate individualized interventions were implemented or adjusted to address the unintended weight loss, as required by the facility’s policy on interventions for unintended weight loss. An after-visit summary later specified that the resident required 2 liters of water per day and 1:1 assistance for water intake and diet orders, but review of the electronic health record showed that from that point forward there was no documentation that the resident actually received 2 liters of water daily. Point-of-care fluid intake records lacked evidence of the ordered hydration, and the DON acknowledged that the record did not document the required 2 liters of water per day or appropriate interventions to prevent further unintended weight loss, in contrast to the facility’s written policy to identify, monitor, and implement individualized interventions for residents with unintended weight loss or malnutrition.
Bird Aviary Windows Not Kept Free of Bird Feces
Penalty
Summary
The facility failed to ensure the windows for 2 of 2 bird aviaries were maintained between routine cleanings and kept free of excessive bird feces. During observation, the Memory Care bird aviary and the Dining Room bird aviary each had 8 windows, and all observed windows had multiple areas of white bird feces on them. Review of the Aviary Service Checklist showed the Memory Care aviary and Dining Room aviary were last cleaned on 7/30/25. In interview, the Administrator stated the facility uses a contracted company from another state to provide quarterly cleaning of the aviaries and that, between quarterly cleanings, no one cleans or enters the aviary unless something urgent needs to be done.
QAA Committee Did Not Include Medical Director at Quarterly Meetings
Penalty
Summary
The facility failed to ensure the Medical Director attended the Quality Assessment and Assurance (QAA) meetings quarterly. The facility reported a census of 145 residents. Review of the QA Meeting Records showed the Medical Director attended the meetings on 5/21/25 and 7/28/25, but was not present at the 3/20/25 quarterly meeting or the 10/15/25 quarterly meeting. During interviews on 12/11/25, the Administrator acknowledged that the Medical Director was not present at the 3/20/25 and 10/15/25 QA meetings and stated she was familiar with the requirement for the QA committee to meet quarterly with required members present. The DON also reviewed the meeting records and acknowledged the Medical Director did not attend those two meetings, stating she expected the Medical Director to be present during the quarterly meetings. Review of the 2025 QAPI Plan stated the QAPI Committee meets minimally bi-monthly with the Medical Director and may decide to meet quarterly rather than bi-monthly or monthly.
Failure to Notify Representative Before Psychotropic Use
Penalty
Summary
The facility failed to notify a resident's representative in advance of the risks and benefits of a psychotropic medication, the treatment alternatives or other options, and to allow the representative to choose the preferred option before the medication was given. Resident #1 had a BIMS score of 0 on the MDS, indicating severely impaired cognition, and diagnoses included dementia, diabetes, and respiratory failure. A physician ordered quetiapine by mouth once daily as needed for aggression and agitation, and the MAR showed the resident received quetiapine 5 times in November 2025 and once in December 2025. The resident's EHR lacked documentation that the representative was notified or consented before administration, and the DON stated on 12/11/2025 that the facility did not obtain consent from the family before giving quetiapine and that staff are supposed to speak with the family about risks versus benefits and document it. The facility policy titled Antipsychotic Medication Used did not include direction on notifying the resident or representative in advance of the risks and benefits, treatment alternatives, or other options.
Resident Property Discarded Before Family Retrieval
Penalty
Summary
The facility failed to ensure that one resident’s personal belongings were retained and returned to the family after the resident’s death. Resident #159 died at 1:50 PM, and the record shows that the family had not finished going through the room and planned to return to collect additional belongings. A communication note documented that the Social Worker misread the note and alerted housekeeping to clean the room, after which the room was cleaned and the belongings were removed. The daughter later reported that several of her mother’s personal items had been thrown away before the family could pick them up, including framed family pictures, childhood photos on a tackboard, a knitted last-name doily, clothing, a wall hanging, and a fleece blanket. The Administrator stated that the family was informed the facility would replace and pay for anything accidentally destroyed, and the DON said financial compensation had been offered. A statement from the Pastor also reflected that the family was apologized to and told the facility would provide financial compensation. The facility’s policy stated that residents or their representatives are advised of the types and amount of personal clothing and possessions they may keep, and that the facility promptly investigates complaints of misappropriation or mistreatment of resident property.
Failure to Submit Updated PASRR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a PASRR for 1 of 2 residents with new mental health diagnoses, identified as Resident #22. The resident’s MDS listed diagnoses of anxiety, depression, and psychotic disorder. The EHR also showed a generalized anxiety disorder diagnosis added on 5/14/19, and later diagnoses of unspecified moderate dementia with other behavioral disturbance and unspecified psychosis added on 10/9/23. The physician’s orders showed quetiapine 25 mg twice daily started on 2/7/23. Resident #22’s Level I PASRR dated 10/21/18 did not include the later diagnoses of generalized anxiety disorder, unspecified moderate dementia with other behavioral disturbance, or unspecified psychosis. During interview, the SW stated the last PASRR Level I for Resident #22 was done on 10/21/18 and that she would submit a new PASRR if significant medication changes or mental wellbeing changed. When asked about the added generalized anxiety disorder diagnosis, the SW stated she should have done one. When asked about the start of quetiapine and the later dementia and psychosis diagnoses, she stated it would be on a case-by-case basis and then said she would be doing a new one now. The ADON stated the facility did not have a PASRR policy and followed the guidelines. The Iowa PASRR Program document stated PASRR evaluation must occur prior to admission, whenever a prior approval is expiring, and whenever a resident experiences a significant change in status.
Failure to Provide Timely Emergency Care After Resident Fall
Penalty
Summary
A resident with a history of a recently repaired right hip fracture and severe cognitive impairment experienced an unwitnessed fall in the facility's bathroom. Following the fall, the resident reported pain in the right hip and required increased assistance with transfers, as documented by both nursing and CNA staff. Despite these changes, the nurse on duty faxed the physician rather than arranging for immediate evaluation or emergency care, and the resident was assisted back to bed by two CNAs. Over the following days, the resident continued to report significant pain, demonstrated by high pain scores and increased need for pain medication, and required two-person assistance for transfers, which was a change from his previous baseline. Multiple staff members, including CNAs and nurses, observed and reported the resident's increased pain and decreased mobility to the nursing leadership. Documentation shows that the resident received PRN Tylenol for pain on several occasions, but the pain persisted and even escalated to severe levels. Despite these ongoing symptoms and the resident's inability to bear weight, the facility did not send the resident for emergency evaluation until several days after the initial fall. The delay in intervention occurred even though staff interviews revealed that several team members believed the resident should have been sent to the hospital earlier due to his change in condition. When the resident was finally sent to the emergency room, he was found to have a new pelvic fracture, hypoxia, and COVID-19. The facility's own policy required staff to respond properly to incidents affecting resident well-being, but the response to this resident's change in condition was not timely. Interviews with staff and nursing leadership confirmed that the resident should have been sent for emergency evaluation earlier, given the clear change in his condition and increased care needs following the fall.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A resident with severe cognitive impairment, a history of dementia, recent hip fracture, and multiple comorbidities required substantial assistance with all activities of daily living and was known to exhibit combative and verbally aggressive behaviors. The resident was dependent on staff for transfers and toileting, often becoming agitated during care, and had a documented history of hitting, cursing, and biting staff. On the night in question, the resident pressed the call light for assistance to the bathroom and was being transferred using a mechanical lift by three CNAs when he became agitated and struck one of the aides. In response, one CNA struck the resident's hand multiple times and verbally retaliated with derogatory language after the resident insulted her. The exchange escalated, with both the staff member and the resident exchanging profanities. The incident was not immediately reported to the nurse by the witnessing staff, and one staff member left the facility soon after. When the incident was eventually reported, an assessment found a reddened area and bruises on the resident's hand and wrist, consistent with the area where the staff member had struck him. Facility documentation and staff interviews confirmed that the staff involved did not treat the resident with respect and dignity as required by policy and resident rights. The staff failed to maintain a professional and respectful environment, instead engaging in physical and verbal altercations with the resident, which did not promote or enhance the resident's quality of life.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required 2-hour timeframe to the Department of Inspection and Appeals and Licensing (DIAL). The incident involved a certified nurse aide (CNA) who witnessed another CNA strike a resident on the hand multiple times after the resident became agitated and hit the staff member. The witnessing CNA did not immediately report the incident to the facility, instead waiting until the following day, which was outside the mandated reporting window. The resident involved had a history of severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5, and required substantial to maximal assistance with all activities of daily living. The resident also had multiple diagnoses, including benign prostatic hyperplasia, diabetes mellitus, arthritis, a recent hip fracture, and mild cognitive impairment. During the incident, the resident exhibited behavioral symptoms such as yelling and physical aggression, which escalated the situation with staff. Upon eventual reporting, the nurse assessed the resident and documented physical findings, including a reddened area and bruises on the resident's hands and wrists. The facility's policy required immediate reporting of all abuse allegations to the charge nurse and subsequent notification to the administrator and DIAL within two hours. However, the delay in reporting by the witnessing CNA resulted in noncompliance with this policy and state requirements.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) assessment for one resident within the required timeframe. The resident was discharged to home, and the discharge summary was dated June 26, 2024. The MDS assessments completed on June 1, 2024, and June 26, 2024, were not transmitted, although previous MDS assessments had been accepted, indicating they were transmitted. During an interview, a Registered Nurse/Care Plan Nurse admitted to completing the discharge MDS but failing to submit it to the Centers for Medicare and Medicaid Services (CMS). The facility did not have a policy for MDS submissions and followed the Resident Assessment Instrument (RAI) Manual, which requires submission of a discharge return not anticipated MDS no later than 14 days after completion. The facility should have completed the MDS within 14 days after the discharge date.
Failure to Reassess Abnormal Blood Pressures
Penalty
Summary
The facility failed to reassess blood pressures for a resident, identified as Resident #67, who exhibited both high and low blood pressure readings. The resident's Treatment Administration Record (TAR) for September and October 2024 included an order to obtain blood pressure and temperature every shift. However, several instances of abnormal blood pressure readings were not reassessed. These included extremely low readings on multiple occasions and a high reading on one occasion. Staff J, an LPN, acknowledged that she did not recheck the resident's blood pressures on specific dates despite recognizing the abnormal values. The Director of Nursing (DON) confirmed that the blood pressures should have been rechecked and that the charge nurse and physician should have been notified. The DON also noted that the blood pressure reading on one occasion did not make sense and acknowledged the lack of further rechecks for the abnormal readings. The facility's policy on measuring blood pressure was referenced, which defines normal, borderline, and hypertensive ranges, as well as conditions like hypotension and orthostatic hypotension. Despite these guidelines, the facility did not adhere to the necessary reassessment and notification protocols for Resident #67's abnormal blood pressure readings.
Failure to Provide Necessary Equipment for Resident's Range of Motion
Penalty
Summary
The facility failed to provide necessary services to prevent the reduction in range of motion for a resident with cerebral palsy and dementia, identified as having a functional loss in range of motion on one side of the upper body. After completing occupational therapy, the resident was provided with specially modified palm guards to protect her hand from contractures. However, multiple observations revealed that the resident did not have the palm guards in place, and staff interviews confirmed that the guards had been missing for some time without any attempts to contact therapy for replacements. The resident's care plan and treatment administration records indicated that she was to wear the palm guard during the day and have rolled gauze in her hand at night. Despite these orders, the resident was frequently observed without the palm guard or any substitute, such as a washcloth or gauze, in her hand. Staff members, including CNAs and LPNs, reported that the palm guards were either lost or discarded, and no new guards were requested from therapy. The lack of palm guards resulted in the resident's fingers digging into her palm, indicating a failure to follow the prescribed care plan. Interviews with staff revealed a lack of communication and understanding regarding the maintenance and replacement of the palm guards. The Director of Nursing expected the nursing staff to coordinate with therapy to obtain new guards if they went missing, but this did not occur. The facility's Restorative Nursing Services Policy emphasized individualized and resident-centered care, yet the failure to provide the necessary equipment for the resident's condition demonstrated a deficiency in adhering to this policy.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident had their call light within reach at all times, which is a requirement to prevent accidents. This deficiency was identified for one of the three residents reviewed for recent falls. The resident in question, who had a moderately impaired cognition with a BIMS score of 10, was independent with bed mobility, walking, sitting, and toilet use. However, the resident reported that their call light was placed approximately eight feet away from their recliner, making it inaccessible. This resident had recently fallen in the bathroom and fractured their arm. The facility's policy required that call lights be within reach of residents while in bed or confined to a chair, a standard that was not met in this instance. Interviews with the Director of Nursing and the Administrator confirmed the expectation that call lights should be within reach at all times when residents are in their rooms.
Unauthorized Catheterization of Resident
Penalty
Summary
The facility failed to ensure that catheterization was performed only with a proper medical order, as evidenced by an incident involving a resident who was catheterized without an order. The resident, who had a Brief Interview of Mental Status (BIMS) score indicating no cognitive impairment, required substantial assistance with toileting hygiene. Despite this, a registered nurse, while still in orientation, mistakenly catheterized the resident without an order, leading to distress for the resident who protested the procedure. The incident was reported by the resident, who expressed dissatisfaction with the nurse's actions and the lack of adherence to proper protocol. The Director of Nursing confirmed that the nurse, who was new and in orientation, confused the residents and performed the procedure on the wrong individual. The facility acknowledged the error, and the nurse involved was subsequently terminated. The incident highlights a lapse in following established procedures for catheterization, which requires a valid medical order.
Facility Assessment Deficiency
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for resident care during both routine operations and emergencies. The assessment did not evaluate the needs of the current residents, including activities of daily living (ADLs), bowel and bladder status, mental abilities, skin integrity, special care requirements, treatments, and medications. The facility, which reported a census of 159 residents, lacked a system to assess these specific needs due to the absence of a form in their current electronic health record (EHR) system. The Director of Nursing (DON) and the Administrator acknowledged the deficiency, noting that the previous process for facility assessment was no longer in use.
Inadequate Infection Control During Medication Administration
Penalty
Summary
The facility failed to implement adequate infection control prevention practices during medication administration. Observations revealed that a Certified Medication Aide (CMA), identified as Staff E, handled medications with bare hands while administering them to residents. Specifically, Staff E was observed touching a methylphenidate tablet and a Vitamin D tablet with her bare hands before placing them into a medication cup for Resident #213. Similarly, Staff E handled a Certavite tablet with bare hands while preparing medication for Resident #26. These actions were contrary to the facility's infection control procedures, which require the use of gloves or other tools to avoid direct contact with medications. Interviews with other staff members, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that the facility's policy prohibits touching oral pills with bare hands. Staff F and Staff G, both LPNs, stated that medications should be handled using a tongue depressor, spoon, or gloves. The DON reiterated the expectation that gloves should be used if there is a need to touch oral pills during medication administration. The facility's Medication Pass Policy/Procedure, revised on the same day as the observations, directed staff to adhere to established infection control procedures, including the use of gloves, during medication administration.
Resident Fall During Van Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, resulting in a fall incident. The resident, who had intact cognition and was independent with transfers, fell while getting off the facility van. The incident occurred when the van driver accidentally left the van lift in the ground level position and fell backward, pulling the resident out of the van to the ground. The resident was later found to have wrist pain but declined further medical evaluation. The resident had a history of cancer, hypertension, and malnutrition and was receiving hospice services. The incident report indicated that the resident fell in his room during a self-transfer and later fell again during the van incident. The facility's investigation revealed that the van driver inadvertently caused the fall by not properly managing the van lift, leading to the resident being tipped out of the wheelchair.
Delayed Response to Fall Leads to Resident's Death
Penalty
Summary
The facility failed to implement timely interventions for a resident following a fall, which resulted in a delay in treatment and an immediate jeopardy situation. The resident, who had a history of impaired vision, moderately impaired cognition, and multiple medical conditions including osteoporosis and spinal stenosis, fell and immediately complained of new rib pain. Despite the resident's family's repeated inquiries, the facility delayed sending the resident to the hospital for 2 hours and 36 minutes after the fall. The facility's policy required a nursing management assessment following an incident, but it took approximately an hour for the nursing supervisor to assess the resident. After the assessment, the nursing supervisor attempted to contact the physician for an order to send the resident to the hospital. The resident was eventually transferred to the hospital, where he was found to have a punctured lung, multiple rib fractures, and injuries inconsistent with the reported fall. The hospital staff intubated the resident and admitted him to the ICU. The resident's condition led to a decision by the family to transition to comfort measures, and he passed away shortly thereafter. Interviews with facility staff revealed a lack of immediate response and assessment following the fall. Staff members noted the resident's complaints of new rib pain, but the decision to send him to the emergency room was delayed, partly due to the facility's requirement for a physician's order for hospital transfers. The facility's failure to act promptly and according to policy contributed to the resident's deteriorating condition and eventual death.
Removal Plan
- Revised post-incident protocol to include provisions for nursing staff in the instance of a suspected injury or change of condition.
- If the house supervisor is not available, the charge nurse can and should contact emergency personnel and arrange transportation to the emergency department if the situation is deemed emergent or urgent.
- If the physician does not respond to a phone call to request to transfer to ED, the supervisor or designee should call emergency response and arrange for transport, followed by continued efforts to contact the physician to notify of the transfer.
- Include a review of resident's medications to determine what factors those medications could potentially have upon the assessment of the resident and potential outcomes.
- Provided reeducation to House Supervisors and charge nurses to include the revised protocol.
- Summary placed on the electronic communication board for all clinical staff to read.
- Policy placed at each nurses' station for staff signature, with tracking of signatures against the staff roster to ensure all nurses received the education prior to their next shift.
- New staff, agency, and contract staff orientation will include the revised policy prior to their first shift.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, exceeding the regulated 15-minute response time for three out of five residents reviewed. Resident #4's call light was observed to be on for 16 minutes before an LPN entered the room, who then failed to address the call light or check if the resident still needed assistance. The LPN's interaction with the resident and her daughter was described as defensive and derogatory. Later, two CNAs entered the room and turned off the call light without addressing the resident's needs. Resident #4 was reported to be unwell, with a temperature and potential dehydration, leading to a planned hospital transfer. Resident #3's daughter reported that the facility often took up to an hour to respond to call lights, causing her father to self-transfer due to frustration and resulting in soiled clothing. She expressed concerns about her father's falls since admission, which were discussed with the facility. Resident #5 reported waiting up to 45 minutes for call light responses, causing her pain when left on the commode. The call light issue was noted to occur on every shift. Another call light was observed to be on for 17 minutes, further indicating the facility's failure to provide timely assistance as required by resident rights.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility staff failed to treat a resident with dignity and respect during care and communication, as observed in an incident involving a Licensed Practical Nurse (LPN) and a resident, along with the resident's family member. On the specified date, the resident's call light was observed to be on for 16 minutes before the LPN entered the room. Upon entering, the LPN brought a nutritional drink and a pain patch for the resident. However, the LPN displayed unprofessional behavior by speaking in a derogatory tone, rolling her eyes, and making negative facial expressions towards the resident and the family member present. The family member reported that this behavior was consistent and had been previously observed. The facility's Resident Rights form, dated October 2017, mandates that residents be treated with respect and dignity, and the LPN's job description emphasizes the importance of maintaining a good attitude at work.
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 90 citations issued within 25 miles in the last 12 months — 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 Mason City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Care And Rehabilitation Center | 0.8 mi | ★★★★★ | 7 | 0 |
| I O O F Home And Community Therapy Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Mercyone North Iowa Medical Services | 3.3 mi | — | 0 | 0 |
| Manly Specialty Care | 9 mi | ★★★★★ | 7 | 0 |
| Nora Springs Care Center | 9 mi | ★★★★★ | 4 | 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.