Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Heritage Care And Rehabilitation Center during CMS and state inspections, most recent first.
Food Held Below Required Hot-Holding Temperature: During meal service, a cook and another cook served multiple items that were below the required hot-holding temp, including mashed potatoes, cauliflower, and French fries. Several residents reported receiving cold or only warm food when eating in their rooms, and the facility policy required TCS foods to be held at 135 F or above.
Improper Glove Use During Meal Preparation: Staff were observed handling ready-to-eat foods with the same gloved hands after touching non-food items and other surfaces during meal service. A cook handled hamburger buns, turkey burgers, soup, and a ham sandwich without changing gloves between tasks, and another cook repeated similar practices while preparing sandwiches. The facility's glove-use policy required hand hygiene, glove changes when changing tasks, and use of proper utensils for food handling.
An LPN, CNAs, and an MDS/RN failed to follow infection control practices during resident care, including not completing hand hygiene between dirty and clean glove changes, not wearing gowns for EBP, and not cleaning catheter tubing during peri care. One LPN gave meds and performed BG testing without hand hygiene before continuing care, staff entered a resident’s room without gowns before brief care, and another LPN performed wound care for a resident with a stage 3 pressure ulcer and urinary catheter without a gown and without hand hygiene after glove changes.
Failure to provide ordered restorative ROM care for a resident with impaired cognition, limited ROM, and multiple mobility-related diagnoses. The care plan called for active and passive ROM and exercises 4 times weekly, but documentation showed only a few restorative sessions in the month, with missing entries for other days. The resident said she was supposed to get therapy to her left leg but usually did not receive it, while the restorative aide could not explain the limited documentation and PT staff said 3 sessions in a month would not be effective.
Failure to Provide Additional Pain Interventions: A resident with CVA, spinal fusion, chronic low back pain, and repeated falls consistently reported pain at 6 to 8, with nighttime pain up to 10 and poor sleep. Although the MAR showed routine oxycodone and acetaminophen, the record lacked documentation that PRN acetaminophen, topical analgesics, or nonpharmacological interventions were offered, used, or refused. Staff acknowledged the resident’s ongoing pain and the absence of documentation showing additional interventions beyond routine meds.
A resident with a history of schizophrenia and dementia experienced an unwitnessed fall, resulting in head abrasions. Despite documenting multiple neurological assessments, an LPN only performed the initial check. Staff expressed concerns about the resident's condition, but the LPN did not reassess. The resident was later sent to the hospital after another LPN noted a change in condition. Video footage confirmed the lack of follow-up assessments, highlighting a deficiency in care.
A facility failed to ensure accurate documentation of assessments for a resident after a fall. An LPN documented neurological assessments that were not performed, as confirmed by video footage. Concerns were raised by other staff, and the resident, with a history of seizures, was sent to the hospital for a change in condition. The facility lacked a policy on falsification of documentation.
Food Held Below Required Hot-Holding Temperature
Penalty
Summary
Food and drink were not kept at a safe and appetizing temperature during the observed meal service. On 8/13/25 from 11:30 AM to 1:20 PM, Staff L and Staff N, both cooks, served residents while temperatures were taken on multiple menu items before service. The measured temperatures included mashed potatoes at 120 F, cauliflower at 110 F, and French fries at 114 F, which were below the facility’s required hot holding temperature. The facility had a census of 61 residents at the time of the observation. Resident interviews supported that food was sometimes served cold. On 8/11/25, Resident #4 reported eating in his room and described the food as cold, stating he had cold scrambled eggs and that the food only felt warm to the touch. Resident #46 said she ate in her room and sometimes got cold food. Resident #12 stated she did not care for the food and said it sometimes came hot and sometimes not, also noting that she ate in her room. The facility’s Food Handling Policy dated October 2023 required TCS foods to be held at 135 F or above, and the Dietary Manager stated on 8/13/25 at 4:21 PM that she planned to request the steam table be looked at and provide more education.
Improper Glove Use During Meal Preparation
Penalty
Summary
The facility failed to follow infection control practices during meal preparation by allowing staff to handle ready-to-eat foods with the same gloves after touching non-food items and other surfaces. During kitchen observation, Staff L completed hand hygiene, put on gloves, and then used the gloved hand to grab a hamburger bun sack, reach in to take a bun, place it on a plate, open the bun, use tongs to place a turkey burger on the bottom bun, and then place the top bun on the burger with the same gloves. Staff L repeated this process several times during meal service. When preparing a peanut butter sandwich, Staff L removed a soiled glove, performed hand hygiene, applied new gloves, handled the bread sack and tie, took bread from the sack, handled peanut butter packets and a knife, spread the peanut butter, assembled and cut the sandwich, and placed it on a plate with soiled gloves before removing the gloves and washing hands. At 12:30 PM, Staff N, Cook, was observed performing hand hygiene and applying gloves, then reaching into the hamburger bun bag, taking a bun, placing it on a plate, opening the bun, using tongs with a gloved hand to place a turkey burger on the bottom bun, and placing the top bun on the burger with the same gloved hand. Staff N then grabbed a plate and bowl, used a ladle to serve soup, and later handled a ham sandwich with soiled gloved hands and placed it on a plate, repeating this process through the rest of meal service. The facility's undated Glove Use policy instructed staff to wear gloves for safe and sanitary food preparation and service, use proper utensils for food handling, wash hands before and after wearing or changing gloves, and change gloves when changing activities or food types or leaving the workstation. The Dietary Manager stated staff were expected to separate the buns prior to serving so tongs could be used to place the bottom bun and product on the top bun, and said education would be done on gloving.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to follow infection control practices during care provided to multiple residents and during a kitchen observation. During medication administration and blood glucose testing for a resident with diabetes and schizophrenia, an LPN administered oral medications, performed a fingerstick blood sugar check, removed gloves after handling the glucometer supplies, and then continued with nasal spray administration without completing hand hygiene or applying new gloves. The resident had intact cognition and was receiving insulin and blood glucose monitoring, and the LPN later acknowledged she forgot to put on gloves before giving the nasal spray and said she should have sanitized her hands and done both. During care for a resident with memory loss, disorganized thinking, an indwelling urinary catheter, and diagnoses including congestive heart failure and inflammatory disorders of the scrotum, two CNAs and an MDS/RN entered the room and began repositioning and brief care. They initially entered without gowns despite the resident’s EBP status, and a nurse had to remind them to put on gowns after they had already checked the resident’s adult brief. One CNA performed peri care and cleaned bowel movement from the resident, but did not clean the catheter tubing or the resident’s hips as part of the peri care. All three staff removed dirty gloves and put on new gloves without completing hand hygiene between glove changes. A separate wound treatment observation involved a resident with intact cognition, non-Alzheimer’s dementia, multiple sclerosis, irritable bowel syndrome, an indwelling catheter, and a stage 3 pressure ulcer on the coccyx. An LPN laid out supplies, washed her hands, and applied gloves, but did not wear a gown even though the resident required EBP for wounds and a urinary catheter. She removed the wound dressing, cleansed the wound, cleaned around the wound, and then cleaned a smear of bowel movement with wipes. After removing dirty gloves, she put on new gloves and continued the wound treatment without completing hand hygiene. The DON observed in the room, and the Administrator and DON later acknowledged that staff should have sanitized their hands between dirty and clean glove changes, should have cleaned the catheter tubing during peri care, and did not follow EBP.
Failure to Provide Ordered Restorative ROM Program
Penalty
Summary
The facility failed to carry out therapy recommendations and provide restorative exercises for Resident #40, who had a BIMS score of 7 and was moderately cognitively impaired. Her MDS identified dependence on staff for toileting hygiene, bathing, and lower body dressing, partial to moderate assistance for upper body dressing, and limited ROM in one side of her upper and lower extremities. Her diagnoses included hip fracture, aftercare following joint replacement surgery, abnormal posture, limitation of activities due to disability, difficulty walking, unsteadiness on feet, and weakness. The care plan directed active and passive ROM and exercises 4 times per week as tolerated to improve or maintain current ROM. The restorative documentation for July 2025 showed only a few recorded sessions for active ROM to the lower extremities, with entries of 10, N on 7/16/25 and 7/23/25, and 15, N on 7/31/25, while the form lacked documentation for the other days in the month. The resident stated she was supposed to get therapy to her left leg but did not usually get it. The restorative aide stated the resident had a restorative program 3 to 4 times a week and that documentation was completed in the EHR, but she could not explain why only 5 sessions were documented for the last 30 days. The DON stated staff were expected to complete therapy recommendations or document refusals, and PT staff stated that receiving restorative care only 3 times in a month would not be effective.
Failure to Provide Additional Pain Interventions
Penalty
Summary
The facility failed to provide additional pharmacological and nonpharmacological pain management interventions for a resident who consistently reported significant pain. Resident #11 had diagnoses including cerebrovascular accident, fusion of the spine, low back pain, and repeated falls, and his MDS indicated pain almost constantly over the prior 5 days. His care plan identified chronic pain related to spinal fusion and directed staff to assess pain, administer ordered pain medication, encourage repositioning, monitor for factors that worsen pain, offer multiple nonpharmacological interventions, notify the physician if pain relief was inadequate, and monitor for opioid-related complications. Resident #11 told staff he had pain ever since his stroke and back surgery, that his pain medication had been reduced from 10 mg to 5 mg, and that Tylenol did not help. He rated his pain as a 7 or 8, described pain down his left leg, and stated his pain reached a 10 at night and interfered with sleep. Observations documented facial grimacing and rubbing of his leg while he reported pain. The MAR showed routine oxycodone and acetaminophen administration, but the record lacked documentation that ordered PRN acetaminophen, Biofreeze, or diclofenac gel were given, and there was no documentation that nonpharmacological interventions were offered or refused. Staff interviews confirmed the lack of documented intervention use. The MDS/Care Plan RN stated the resident was a drug seeker and said he received pain medication, while the APRN stated the resident received an appropriate amount of oxycodone and that the facility had many interventions available, but acknowledged the chart lacked documentation of interventions offered, refused, or tried despite repeated pain scores of 6 or 7 and a care plan target pain level of 5. The DON and nurse consultant also acknowledged the absence of documentation showing interventions were offered or refused. The facility pain policy required pain assessment, use of nonpharmacological measures when appropriate, reassessment after PRN medication, and notification of the physician if pain remained unrelieved.
Failure to Conduct Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to provide follow-up assessments and interventions for a resident who experienced an unwitnessed fall. The resident, who had a history of schizophrenia, chronic ischemic heart disease, non-Alzheimer's dementia, and renal insufficiency, was found on the floor with abrasions on his head and wrist. Despite the resident's report of hitting his head, the covering LPN, Staff A, documented that she completed eight neurological assessments, but video footage and staff interviews revealed that only the initial assessment was conducted. Staff members, including CNAs and a CMA, repeatedly expressed concerns about the resident's condition, noting changes such as leaning, tremors, and altered mental status. Despite these observations and requests for further assessment, Staff A did not perform the necessary neurological checks or reassess the resident. The resident was eventually transferred to the hospital after another LPN, Staff B, observed a change in the resident's condition and contacted the on-call provider. The facility's video footage confirmed that Staff A did not perform the documented neurological checks, and the facility's policy required immediate notification of the resident's physician and responsible party in the event of an accident or change in medical condition. The failure to conduct proper assessments and follow facility policy resulted in a deficiency in the care provided to the resident.
Failure to Accurately Document Resident Assessments
Penalty
Summary
The facility failed to ensure accurate documentation of assessments for a resident, leading to a deficiency. Staff A, an LPN, documented that she completed neurological assessments on a resident following a fall, which she did not actually perform. The incident was brought to light when the Administrator noticed a delay in documentation of the fall in the progress notes and upon further inquiry, Staff A vaguely admitted to not performing the neuro checks. Video footage from the facility confirmed that Staff A did not conduct all the neuro checks as documented, showing her entering the resident's room only once and not returning for subsequent checks. The Director of Nursing (DON) and the Administrator reviewed the situation after concerns were raised by other staff members. Staff E, a Certified Medication Aide, initially reported suspicions that Staff A did not perform the neuro assessments. Despite Staff A's claims of having completed the checks, the video evidence contradicted her documentation. The resident, who had a history of seizures, was sent to the hospital for a change in condition, where it was later reported that he had suffered a heart attack. The facility lacked a policy related to the falsification of documentation, which contributed to the deficiency.
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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.
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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) |
|---|---|---|---|---|
| Good Shepherd Health Center | 0.8 mi | ★★★★★ | 7 | 0 |
| I O O F Home And Community Therapy Center | 2 mi | ★★★★★ | 3 | 0 |
| Mercyone North Iowa Medical Services | 4.1 mi | — | 0 | 0 |
| Nora Springs Care Center | 8.3 mi | ★★★★★ | 4 | 0 |
| Manly Specialty Care | 9.5 mi | ★★★★★ | 7 | 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.