Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 I O O F Home And Community Therapy Center during CMS and state inspections, most recent first.
A resident’s MDS incorrectly coded tobacco use as no, even though the resident had intact cognition, was documented elsewhere as a current smoker, and staff and the resident confirmed ongoing smoking. Records included a physician plan noting 1 pack per day, a smoking safety assessment showing independent smoking, a care plan identifying the resident as a smoker, and interviews in which the DON acknowledged the MDS was not accurate.
The facility failed to notify the State LTC Ombudsman of hospitalizations for three residents, resulting in a deficiency. A resident was transferred to the hospital and returned without documentation in the Ombudsman report. An LPN admitted to not knowing hospitalizations needed to be included, leading to the omission of required documentation.
A facility failed to complete a discharge MDS for a resident who was discharged to the hospital. The resident's discharge on December 24 was not documented in the MDS log, resulting in a 63-day overdue assessment. The MDS Coordinator was unaware of the discharge, and the DON acknowledged the oversight.
A resident with multiple comorbidities, including diabetes and a left hip fracture, developed an unstageable pressure ulcer due to the facility's failure to conduct and document twice-daily skin checks under a knee immobilizer. The resident's treatment administration record lacked orders for these checks, and staff interviews confirmed the assessments were not performed. The ulcer, caused by the immobilizer, was complicated by the resident's underlying health conditions and poor nutritional intake.
The facility failed to maintain safe holding temperatures for both hot and cold foods, as required by their policies. Observations revealed that several foods were not heated to the necessary internal temperature of 135 degrees Fahrenheit before being served, and milk was left on the counter at an unsafe temperature. The Food Services Supervisor confirmed that staff had been trained on the correct procedures, but these were not followed.
The facility failed to maintain sanitary conditions in the kitchen and during meal preparation, with staff observed handling food and utensils improperly, not changing gloves, and not measuring food portions correctly. Specific incidents included staff touching food with bare hands and not performing hand hygiene.
The facility failed to identify and correct high risk, high volume, and problem-prone quality deficiencies, as evidenced by repeated deficient practices identified in previous surveys. The DON reported that QA meetings are held monthly to discuss concerns and corrective actions, but the QAPI Plan indicated a need for more effective monitoring and improvement.
The facility failed to complete Significant Change MDS assessments within the required 14-day timeframe for two residents who were enrolled in hospice services. The MDS Coordinator misunderstood the timeline for completing the assessments, and the facility did not have a specific policy for MDS completion, relying instead on the RAI Manual guidelines.
The facility failed to ensure all diagnoses present on admission were included in the PASRR for a resident. The PASRR documented only one mental health diagnosis, while the admission report listed six. Interviews revealed no process was in place to compare and review new resident admission diagnoses with the PASRR.
The facility failed to update the care plan for a resident who had a new catheter order. Despite documentation of the new catheter in the progress notes and telephone order, the care plan did not reflect this change. The MDS Coordinator acknowledged that the care plan should be updated promptly, but this was not done. The facility's policy also lacked guidance on updating care plans for changes in nursing care needs.
Inaccurate MDS Tobacco Coding
Penalty
Summary
The facility failed to complete the MDS assessment to accurately reflect Resident #6’s tobacco status. The resident’s MDS dated [DATE] included a BIMS score of 15, indicating intact cognition, but Section J Health Conditions coded that the resident did not utilize tobacco. The MDS Section V Assessment Administration was certified as accurate by Staff A, RN, who signed the completed Section J Health Conditions on 5/30/25. Other records and interviews showed Resident #6 was a smoker. A physician visit patient plan dated 5/6/25 listed the resident as smoking 1 pack per day, and a Smoking and Safety assessment identified the resident as using tobacco and smoking independently, with refusal to wear a smoking apron after education. A progress note documented the resident frequently went outside to smoke, the care plan identified the resident as a smoker, and staff interviews and the resident’s own statements confirmed current smoking. The DON acknowledged the MDS was not accurate and stated the resident was supposed to keep cigarettes and a lighter locked at the nurse’s station or in his personal car.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of hospitalizations for three residents, resulting in a deficiency. Resident #2 was transferred to the hospital on December 24, 2024, and returned to the facility on December 26, 2024. The facility's records lacked documentation of this transfer in the Notice of Transfer Form to the Long Term Care Ombudsman for December 2024. Similarly, Resident #27 was transferred to the hospital on November 20, 2024, and returned on November 22, 2024, but the transfer was not documented in the November 2024 report. Resident #64 was transferred to the hospital on January 19, 2025, and returned on January 27, 2025, yet her transfer was also missing from the January 2025 report. The deficiency was identified through clinical record review, facility document review, and staff interviews. Staff A, a Licensed Practical Nurse and Admissions Coordinator, admitted during an interview that she was responsible for adding residents to the Ombudsman's report each month but was unaware that hospitalizations needed to be included. This oversight led to the omission of the three residents' hospital transfers from the required documentation, contributing to the facility's failure to comply with notification requirements.
Failure to Complete Discharge MDS for Hospitalized Resident
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) for one resident who was discharged to the hospital. The resident was discharged on December 24, 2024, and returned to the facility on a later date. A review of the MDS log showed that the last assessment was a quarterly MDS on October 11, 2024, followed by an entry MDS on December 26, 2024. However, there was no discharge MDS completed for the resident's hospital discharge on December 24, 2024, which was 63 days overdue at the time of review. The MDS Coordinator was unaware of the resident's discharge to the hospital and questioned if a late MDS could be completed. The Director of Nursing acknowledged the oversight and indicated that the MDS Coordinator would complete the overdue discharge MDS to comply with requirements.
Failure to Prevent Pressure Ulcer Due to Inadequate Skin Checks
Penalty
Summary
The facility failed to provide proper assessment and treatment to prevent pressure ulcers for a resident with a facility-acquired pressure ulcer. The resident, who had a history of cancer, hypertension, anemia, diabetes mellitus, bacteriuria, and a left hip fracture, was at risk for developing pressure ulcers. Despite this risk, the facility did not document the required twice-daily skin checks under the resident's knee immobilizer, which was supposed to be removed or loosened for these checks. This oversight led to the development of an unstageable pressure ulcer on the resident's left lower extremity. The resident's treatment administration record (TAR) lacked orders for the necessary skin checks, and staff interviews revealed that the twice-daily assessments were not documented. The resident's condition was further complicated by underlying comorbidities, including type 2 diabetes and a history of chondrosarcoma, as well as poor nutritional intake and immobility due to a left femur fracture. These factors likely contributed to the rapid deterioration of the wound, which was initially masked by thick scales of hyperkeratosis on the resident's left lower extremity. The deficiency was identified when a skin issue was reported, and an incident report noted a pressure ulcer caused by the bar of the knee immobilizer. The wound was described as having slough, eschar, and granulation tissue, with cellulitis extending from the knee to the ankle. The Director of Nursing confirmed the lack of documentation for the required skin assessments, and the facility's failure to adhere to the prescribed care plan led to the development of the pressure ulcer.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe holding temperatures for both hot and cold foods, which is essential to prevent foodborne illness. Observations on 3/19/24 revealed that pureed vegetables and gravy were not heated to the required internal temperature of 135 degrees Fahrenheit before being served to residents. Post-meal temperature checks showed that several foods, including pureed vegetables, ground pork, pork loin, sweet potatoes, and gravy, did not maintain the necessary internal holding temperature of 135 degrees Fahrenheit. Additionally, the steam table was found unplugged, and the pork loin was placed on the counter instead of the steam table. On 3/21/24, milk was observed sitting directly on the counter during breakfast, with a post-meal temperature of 58.5 degrees Fahrenheit, well above the safe limit of 41 degrees Fahrenheit for cold foods. The facility's policies on safe food preparation and distribution were not followed. These policies instructed staff to cook foods to a hot holding temperature of 135 degrees Fahrenheit and to avoid using steam tables to heat food. The policies also required reheating hot pureed, ground, or diced foods that had fallen below 141 degrees Fahrenheit to 165 degrees Fahrenheit for 15 seconds before serving. The Food Services Supervisor confirmed that staff had been trained on these policies and were expected to follow them, including keeping milk on ice to maintain a temperature below 41 degrees Fahrenheit. However, these procedures were not adhered to, leading to the observed deficiencies.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and during meal preparation and service. Observations over several days revealed food particles on the floor, counters, and equipment, including the steam table and dishwashing station. Staff were seen handling glasses by the drinking rims, not measuring food portions correctly during puree preparation, and using the same gloves to touch multiple surfaces and food items without changing them. Additionally, desserts were transported uncovered, and serving utensils were not kept clean or used properly. During meal preparation, staff were observed engaging in unsanitary practices such as touching food with bare hands, not changing gloves after touching different surfaces, and using the same utensils for multiple tasks. For example, a staff member used tongs to remove a lid and then used the same tongs to serve food. Another staff member touched bread, plates, the oven handle, and their glasses without changing gloves. These actions were contrary to the facility's policies on safe food preparation and cross-contamination. Specific incidents included staff removing crusts from garlic bread with bare hands and serving it to residents without performing hand hygiene. The Food Services Supervisor acknowledged the expectations for food handling and cleanliness but admitted to not being aware of certain procedures, such as the pureed diet portion sizes chart. The facility lacked specific policies on handling dishes, puree procedures, and glove use in food preparation, contributing to the observed deficiencies.
Failure to Identify and Correct Quality Deficiencies
Penalty
Summary
The facility failed to provide satisfactory evidence that they identified their own high risk, high volume, and problem-prone quality deficiencies and made a good faith attempt to correct them. This was evidenced by repeated deficient practices identified during the facility's previous survey completed on 12/15/22, a complaint and facility-reported incident survey completed on 8/11/23, and current survey investigations. During an interview, the DON reported that QA meetings are held monthly to discuss each department's areas, audits, and concerns, including prior deficiencies from previous surveys. However, the QAPI Plan dated August 2023 directed the facility to examine and improve care or services in areas needing attention, indicating that the committee meets monthly to review the plan, interventions, and monitor effectiveness.
Failure to Complete Significant Change MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that Significant Change Minimum Data Set (MDS) assessments were completed within 14 days of identifying a significant change in condition for two residents. Resident #37 was enrolled in hospice services on 2/27/24, but the Significant Change MDS was not completed by the required date. Similarly, Resident #57 began hospice services on 2/19/24, but the MDS was not signed as complete until 3/13/24, which is outside the required 14-day timeframe. The MDS Coordinator admitted to misunderstanding the timeline for completing the MDS assessments, believing she had 14 days to set an Assessment Reference Date and an additional 14 days to complete the assessment. The facility did not have a specific policy for MDS completion and was following the RAI Manual guidelines. The deficiency was identified through record reviews and staff interviews. The RAI Manual clearly states that a Significant Change MDS must be performed within 14 days when a terminally ill resident enrolls in a hospice program. This is to ensure a coordinated plan of care between the hospice and the nursing home. The failure to complete the MDS assessments within the required timeframe indicates a lapse in following the established guidelines, which could impact the quality of care provided to the residents.
Failure to Ensure Accurate PASRR Documentation
Penalty
Summary
The facility failed to ensure all diagnoses present on admission were included in the Preadmission Screening and Resident Review (PASRR) for one resident. The PASRR for the resident documented only one mental health diagnosis, major depressive disorder, while the Transfer/Discharge Report upon admission listed six mental health diagnoses, including pseudobulbar affect, delusional disorders, major depressive disorder, other symptoms and signs involving cognitive functions and awareness, adjustment disorder with mixed disturbance of emotions and conduct, and anxiety disorder due to known physiological condition. Interviews with the Social Worker and Admission Coordinator revealed that there was no process in place to compare and review new resident admission diagnoses with the PASRR to ensure they matched.
Failure to Update Care Plan for Catheter
Penalty
Summary
The facility failed to ensure that the care plan for one of the three residents reviewed for catheters was updated to include information and instructions on the care of the catheter. Specifically, Resident #37 had a new order for a catheter on 2/28/24, as documented in the progress notes and telephone order. However, a review of the resident's care plan on 3/19/24 revealed that it did not include any information about the catheter. During an interview on 3/20/24, the MDS Coordinator stated that she would update the care plan as soon as she found out about a new catheter, but this was not done in this case. Additionally, the facility's undated policy on comprehensive care planning lacked instructions on when to update care plans for changes in nursing care needs.
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 94 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) |
|---|---|---|---|---|
| Good Shepherd Health Center | 1.7 mi | ★★★★★ | 7 | 0 |
| Heritage Care And Rehabilitation Center | 2 mi | ★★★★★ | 7 | 0 |
| Mercyone North Iowa Medical Services | 2.7 mi | — | 0 | 0 |
| Oakwood Care Center | 8.9 mi | ★★★★★ | 5 | 0 |
| Nora Springs Care Center | 10.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for I O O F Home And Community Therapy Center.
100% money-back within 48 hours.
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.